Final Exam: Book Discussion

What follows is an essay I wrote about Final Exam: A Surgeon’s Reflections on Mortality. 

“I had never expected to deal with the dying so intimately or to face mortality so directly.” Pauline Chen’s words reflect what I think many in the medical profession feel. She notes earlier in the book that she went to medical school to save people, not care for the dying. I think the potential for cure draws many to medicine. Whether directly or indirectly, we have felt the pain and dismay of disease and medicine offers a way to treat or even prevent that suffering. But the limitations of medicine become clear very quickly. We cannot treat or prevent all suffering, and even if we could we cannot prevent death. Death is something that each physician must face. As a transplant surgeon Dr. Chen is keenly aware of this fact. Her book takes us on her journey learning how to better respond to death and fill a huge void in her education.

I cannot remember a lecture on death in medical school. I know we talked about palliative care and hospice but I can think of little mention of what the death process looks like or how to care for someone who is dying. Dr. Chen had a similar experience. She notes the various ways she was exposed to death throughout her training, first with a cadaver in medical school, then as a part of her first code and then the first patient to die under her care. But the training in how to respond to death was part of the “hidden curriculum” of medical education, it was something she picked up from those around her.

Some examples made her uncomfortable like the resident who showed her how to declare someone dead, claiming “See how easy it is?” Other examples were more positive, like the attending physician who stayed with a family as their father was dying and explained what was happening. This changed how she interacted with dying patient’s families. “I stopped slipping away from my dying ICU patients and their families. Instead with my hand in my pocket, I would usher the families into the ICU. I would bring them to their loved one’s bedside and close curtains around not them but us. I would point to the irregularities on the monitor and describe the characteristic last breaths of the dying. I would touch family members, embrace those who looked particularly lost, and tell them of the final comfort of their presence.”

This passage resonated with me. I know if I were in that situation I would make any excuse to not be around a family during that time. I would justify it in my head, and tell myself I would be intruding in their moment. But this passage challenges me to face my own discomfort. In the midst of such sadness and confusion, I imagine it would be a great comfort to have someone explain what was happening when a loved one was dying. If I chose to miss that opportunity because of my own fear I would be performing a disservice to a family.

One of Dr. Chen’s more disturbing stories was about an infant. The boy named Max was born with a severe defect and required multiple surgeries to correct it. These surgeries led to complications which led to more surgeries. One of the complications was the need for a liver transplant. Dr. Chen’s team took Max to the OR on twelve separate occasions. He died as a result of a fungal infection. Dr. Chen was talking about the case with a nurse who remarked, “Maybe it was a good thing, huh? I mean, how much can you do to a person?”

There does seem to be a point in medicine where the treatment can become worse than the disease. This is hard to think about, especially with children. Stopping treatment may be viewed as giving up. With an infant there can be no comfort in saying, “Well he lived a good, full life.” But as I read the story about Max, I wondered how I would feel if he were my child. If I truly wanted the best for him would I continue to put him through multiple surgeries for a slim chance of a normal life? I truly do not know the answer. But it helps me to try and put myself in a parent’s shoes. I can use that to try and guide conversations about the care I will provide.

As a pediatrician I may not deal with death as much as other specialties. However I still need the tools and experience to guide parents and children through such an ordeal. Final Exam helped me realize some of the gaps in education I have in regards to issues surrounding death and gave me some ideas to think about how to address those gaps. While I still fear being around death (especially with children) I think I will approach the issue with more self-awareness. This will allow me to recognize my fears and subsequently better serve my patients and their families.

I pose this question to my readers: How will you deal with death as a physician?

AAP Conference and Step 2 CS

I’ve had a busy week. Last weekend I went to the American Academy of Pediatrics National Conference in Orlando (thank you AAP for the generous scholarship!) and yesterday I got back from Step 2 CS in Chicago.

The conference was a great experience, I met some awesome people and gained a better appreciation for what exactly the AAP does. I came away very impressed. The AAP does some great work overseas (see the Helping Babies Breathe project) as well as lobbying for children’s health in the United States.

Have I mentioned that I love Pediatrics? One day I’ll write about what led me to choose it as a specialty.

I also heard Atul Gawande speak! He’s a cool dude. He talked about how complex medicine is becoming and how we need better tools to handle this complexity (he advocates for the use of checklists). Good stuff.

Step 2 CS on the other hand was not so much fun. For those who don’t know, Step 2 CS is the “practical” Step exam. You see twelve fake patients and write notes on each of them. It also costs $1200.

I’m not a fan of this test for a few reasons. Check out this article which states:

“Of 17,852 examinees taking the exam in a given year, we predict that only 32 per year would not pass the exam on a repeat attempt. Even if no examinee had to use a loan to pay for the exam, the cost of identifying a single “double failure” would be $635,977; using the adjusted expenditure figure of $36.2 million, we calculate the cost as $1.1 million.”

Basically it’s an incredibly expensive test that serves little purpose.

Here is my question: why can’t we trust medical schools to administer this test? Get the AAMC to require a similar exam that meets certain standards in order to be an accredited as a medical school. Creighton already does this in order to prepare us for Step 2 CS and I have a feeling many other schools do as well.

Cut out the huge fees, cut out the inconvenient travel that interferes with our actual education (CS is only administered in five cities across the US) and cut out another source of anxiety for medical students. I see no downside to this.

Medical school sometimes seems like a series of hoops to jump through. While many are necessary, Step 2 CS seems especially arbitrary.

Anyway, sorry about the rant. Thanks for reading- stay tuned to the blog the next couple weeks. I am going to start giving away books that I no longer need and want to see others use! For free! It will be awesome.