Review of Final Exam by Pauline Chen

In this excellent book, Chen, a transplant surgeon, chronicles with vivid clarity her own personal struggle to deal with death in her personal and professional lives. Death is obviously a daily reality for any practicing doctor, but paradoxically, the medical profession is in some ways in denial about death, since, after all, its whole existence is predicated on the assumption that death is the enemy. This paradox is built into the fabric of the medical community, often leading to emotionally unhealthy coping mechanisms among doctors and, ultimately, unsatisfactory end-of-life care of patients.

Chen is not the first to notice this paradox or to write about it, but what makes her book stand out is her gift for telling her own stories, each of which challenges readers to confront their own fears and inconsistent attitudes towards death, and seek a better solution. Rather than say more, I include below an excerpt, which will tell you more about the book than any prosaic description of mine will.

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Nine days after his operation, on one of his better days, Frank motioned to me to sit next to him. I sat at the edge of his bed, and he put his hand in mine.

“You got it all out, didn’t you?” he asked. His eyes were sharper than they had been but still looked slightly filmy.

I nodded. “The pathology report said that all the margins were clear of tumor.”

“That’s great,” Frank replied slowly. He closed his eyes and then asked quietly, “Doc, how am I doing?” He squeezed my hand; those beautiful Cary Grant cheekbones jutted out sharply beneath his loose skin. I heard his daughter behind me, trying to muffle high, hiccoughed sobs; she sounded like an injured bird.

“Frank,” I said. He opened his eyes, and his gaze slowly drifted over to me. I felt the familiar tightening around my throat. Thoughts rumbled around in my chest, like acidic, gaseous bubbles. I opened my mouth; the words popped out and hung in the air. “Your liver is struggling,” I said.

Frank nodded. I had told him the obvious.

But Frank’s liver was not struggling; it was failing. I knew that in the next few days he would likely fall into a coma and die. As I sat next to him, the inevitable repeatedly playing in my mind, I could not bring myself to describe that outcome. Instead, I wished to melt away and find myself back in that time before I had met Frank, when being homesick simply meant a place and a distant memory and not the shared joke and camaraderie with a patient whose death I felt all but responsible for. As I sat there, I wanted to forget my promise to stay with him, to erase my commitment to be his surgeon, and to take back the operation I had performed.

Instead, I said, “Well, let’s just see how the numbers look tomorrow.”

Frank looked at me. “I’m not going back to New Britain anytime soon, am I?”

“I don’t think so, Frank,” I said quietly. “I am so sorry.”

Frank smiled, more radiantly than he had in days. “Doc, you did your best,” he said slowly, “and I am grateful. Like I told you, if I’m going to go, this is the way I want it to happen.” He took my hand and with a force that surprised me, pulled me close to his face. I could smell the spoiled sweetness of his breath. “Just keep me comfortable,” he whispered. He squeezed my hand and as he let go, repeated the words once more. “Just keep me comfortable.”


Just over two weeks after his operation, Frank died. I went to his room minutes after he passed away; his three grown children and their spouses, all exhausted, surrounded his bed. “I need to pronounce his death,” I said. They nodded, and I heard myself add, “May I have a few minutes alone with Frank?”

One by one, they embraced me as they left the room. When they closed the door, I half expected Frank’s charisma to reignite, but the room remained dark and so silent that I could hear my own breathing. Frank’s eyes were closed. His body, already pale, was perfectly still; his lips were slightly parted and pale blue; and his cheeks were sunken and unmoving, weighing down against those glorious arches of bone.

I knew the steps I had to perform—listen to the heart, listen to the lungs, pinch the flesh—but I could not bring myself to do it. Instead, I pulled up a chair and sat and waited, watching him, hoping he would open his eyes, flash that grin, and begin recounting Mr. Martin’s misadventures with his buttons. I looked down at Frank’s hands; they were now whitish, and his fingers were frozen in a gentle curl. I took his right hand and held it; it wasn’t so cold yet. I wanted to feel his grasp and to hear him tell me again that this was how he had wanted it.

I fell back in my chair, wanting desperately for the tears to come forth to release the ache. But nothing came, nothing except for a faint rim of wetness around my eyes, easily dabbed dry with my fingers.

Six months later I received an envelope from Frank’s daughter; she enclosed a letter, a photograph of Frank, and a small remembrance card from his memorial service in Connecticut. “I’m sorry that it’s taken me so long to send this,” she wrote in her letter. “My father was so fond of you, and it was your spirit that gave him the strength to be himself in the worst of situations.”

The picture of Frank was from before I had met him, of a younger, more robust man with the same smile. On one side of the remembrance card was the date of Frank’s service; on the other side, a poem he had chosen several years before. As I read through the poem, I heard Frank’s voice grow stronger in my mind until, at the very end, each line lurched from the staccato of that familiar accent.

So if you need me, call and I will come.
Though you can’t see or touch me, I’ll be near.
And if you listen with your heart,
You’ll hear my love around you soft and clear.
And then, when you must come this way along,
I’ll be waiting with a smile and say, “Welcome Home.”

I put the card down and felt a sudden wave of relaxation across my arms, surging up to my throat. It felt as if the cartilaginous rings around my trachea loosened for a moment and great breaths of air could at last pass through. I opened my mouth, and in the quiet of my office, began to cry.

Posted January 2009

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