A doctor learns to cope with death

In her new book, a surgeon explores the ways in which physicians respond to dying patients.

By Cathy Shufro

Pauline W. Chen, M.D., HS ’98, often recalls the words of the late Yale surgeon C. Elton Cahow, M.D. She once heard him remonstrate with an exhausted resident for thinking he could head home without checking on a certain patient.

“Once you put your hands on a patient,” Cahow said, “they’re yours.”

Chen liked to think she was keeping close watch over all her patients. But something was still wrong: “As early as internship,” she said, “when patients were dying, I found it difficult to go into their rooms, to talk to their families, to discuss their diagnoses and prognoses.” She even shunned a dear friend with terminal cancer.

And her fellow physicians generally shared her anxiety about death. “We’re all susceptible to this,” she said in a recent telephone interview from her home near Boston. “Dying is frightening.”

This fundamental human anxiety, she said, is ratified by medicine’s “hidden curriculum.” When a patient’s death was imminent, Chen often saw attending physicians close the curtain around the patient and the grieving family, and then depart. Chen did the same. “We thought that family members wanted to be alone at the end,” she recalls. “It never occurred to most of us that the actual process might be frightening, and that we could alleviate that fear by being present. And perhaps too, some of us—I include myself here—did not have the insight to realize that we were also leaving them alone because it was easier for us to stay away from the dying altogether.”

“This deeply rooted angst about death,” she later wrote, was being passed on by doctors from one generation to the next “like some tragic hereditary disease.”

Chen said that physicians recognize their limitations. Almost half the oncologists in one study described themselves as only “poor” or “fair” at breaking bad news. Chen herself abandoned a favorite patient to painful and futile end-of-life care because she could not bear to see him diminished by his cancer. In the idiom of her Taiwanese heritage, the young man became a wan ong kuei, a restless soul who haunted her.

Five years ago, pregnant with twins, she took time off from her work as a transplant surgeon at ucla to care for her daughters and write about the ways in which physicians cope with death. Her book, Final Exam: A Surgeon’s Reflections on Mortality, was published by Alfred E. Knopf in January.

Chen begins Final Exam at the moment when she unveils the cadaver that she will dissect as a medical student. Through anecdotes from medical school at Northwestern and residency at Yale, she traces her growing awareness of the extent to which doctors deny death, and tells of the moment midway through residency when an attending surgeon provided a better model. The surgeon closed the bed curtain around a dying patient but did not leave. He remained inside the curtain, sitting with the patient and family during the final hour of the patient’s life. “It was a major turning point,” Chen recalls. “I realized that I could do more than just cure. I could be there for my patients and their families.” She might offer what the medical anthropologist Arthur Kleinman, M.D., calls “empathic witnessing.”

“My greatest hope for the book,” she said, “is to get people to talk about the issue and to share their anxieties.” Although she recognizes that complex cultural, psychological and institutional forces determine how we cope with death, “the more awareness there is, the greater the chance that we’ll improve end-of-life care for all of us.”

Chen now works full-time as a writer, lecturer and consultant. Her blog carries a link to an excerpt from the book, which was published in The New York Times Magazine last December: www.paulinechen.com.

Bookshelf focuses on books and authors at the School of Medicine. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.

Book notes

Complications in Surgery and Trauma
edited by Stephen M. Cohn, M.D., with contributions by Edward Lubin, M.D., Ph.D., FW ’01, Deepak Narayan, M.D., M.B.B.S., assistant professor of surgery, John A. Persing, M.D., professor of surgery (plastic) and neurosurgery, Michael J. Robbins, Joseph H. Shin, M.D., HS ’97, associate professor of surgery, and Raymond S. Sinatra, M.D., Ph.D., professor of surgery (Informa Healthcare) This text offers practical, detailed information on avoiding and managing complications resulting from surgical interventions in the operating room, emergency room and intensive care unit. It covers a variety of pre-, intra- and postoperative events, analyzing complications in all surgical disciplines and suggesting protocols for preventing them.

Colorectal Cancer: Evidence-Based Chemotherapy Strategies
edited by Leonard B. Saltz, M.D., with contributions by Edward Chu, M.D., professor of medicine and pharmacology, Richard Kim, M.D., FW ’06, and M. Wasif Saif, M.B.B.S., associate professor of medicine (Humana Press) This evidence-based and data-driven guide presents reviews of cutting-edge therapies for colorectal cancer. The opening chapters outline contemporary thinking about the biology of colorectal cancer, screening and potential methods of chemoprevention. Subsequent chapters present uses of cytotoxic chemotherapy and weigh the potential for incorporating innovative biological therapy. The concluding chapter explores emerging drug paradigms and their potential for treating colorectal cancer.

Obstetric and Gynecologic Anesthesia: The Requisites
by Ferne R. Braveman, M.D., professor of anesthesiology and of obstetrics, gynecology and reproductive sciences (Mosby) This text discusses anesthesia for female patients during common surgical procedures, including oncologic and nonobstetrical procedures and fetal surgery. Other topics include pain management for high-risk obstetric patients and pharmacology. Each chapter includes case studies.

Management and Treatment of Scars: Procedures in Cosmetic Dermatology Series
by Kenneth A. Arndt, M.D. ’61, HS ’62 (Saunders) This reference presents practical guidance for revising scars using medical treatments, light/laser treatment and surgical and nonsurgical procedures. The book offers step-by-step guidance on proper techniques, pitfalls and “tricks of the trade,” along with photographs and illustrations of cases discussed.

Counseling and Psychotherapy Essentials: Integrating Theories, Skills and Practices
by Glenn E. Good, Ph.D., and Bernard D. Beitman, M.D. ’68 (Norton Professional Books) This textbook aligns students’ classroom experience with the demands of actual clinical practice, in which clinicians do not hew to a single theoretical line but, rather, mix schools and methodologies in order to address their clients’ needs.

Ocular Angiogenesis: Diseases, Mechanisms and Therapeutics
by Colin J. Barnstable, D.Phil., professor of ophthalmology and visual science and of neurobiology, and Joyce Tombran-Tink, Ph.D. (Humana Press) This book surveys current clinical and basic knowledge concerning abnormal growth of blood vessels in the eye. The authors also identify and assess the most promising approaches and discuss the challenges encountered in developing therapeutics for ocular neovascular diseases. This text includes a CD with color versions of figures used in the book.

Visual Development, 2nd ed.
by Nigel W. Daw, Ph.D., professor emeritus of ophthalmology and visual science (Springer) Written for medical students, graduate students and postdocs, this book describes the development of the visual system, the effects of visual deprivation and the mechanisms by which visual deprivation produces its effects.

Menstrual Disorders: A Practical Guide
edited by Deborah B. Ehrenthal, M.D., Matthew K. Hoffman, M.D., and Paula J. Adams Hillard, M.D., with contributions by Henry M. Rinder, M.D., associate professor of laboratory medicine (The American College of Physicians) Designed for the primary care clinician, this book is divided into three sections. The first discusses the adolescent patient, the second covers the range of disorders that patients may experience from adolescence through menopause and the third examines the relationship between menstrual disorders and other medical illnesses.

Extreme Prematurity: Practices, Bioethics and the Law
by Geoffrey Miller, M.D., professor of pediatrics and neurology (Cambridge University Press) This book examines issues surrounding the clinical management of extremely premature neonates in the context of modern neonatal intensive care. The text covers the epidemiology of extreme prematurity and patient care practices in different parts of the world; bioethics considerations, including ethical theories, moral principles and quality-of-life issues; national and international guidelines; and medical law in the United States and elsewhere.

Field Guide to Bedside Diagnosis, 2nd ed.
by David S. Smith, M.D., associate clinical professor of medicine (Lippincott Williams & Wilkins) This book enables students and physicians to navigate the path from collecting information on the patient’s symptoms and presenting signs to reaching a diagnosis. The guide is organized to parallel the diagnostic reasoning process, providing a differential overview of probable causes, a diagnostic approach for each differential diagnosis, and the specific clinical findings that point to diagnosis.

Metabolic Syndrome and Cardiovascular Disease: Epidemiology, Assessment and Management
edited by Nathan D. Wong, M.P.H. ’87, and Andrew J. Krentz, M.D. (Informa Healthcare) This text addresses the epidemiology, diagnosis, assessment and management of patients with metabolic syndrome—focusing on implications for cardiovascular disease risk. With tables, flowcharts and practice guidelines, this resource analyzes recent clinical trials, compares and assesses new and emerging therapies and provides recommendations for improving the assessment and treatment of patients.

Principles and Practice of Geriatric Psychiatry
edited by Marc E. Agronin, M.D. ’91, and Gabe J. Maletta, M.D., Ph.D. (Lippincott Williams & Wilkins) This book describes in detail the neurologic and neuropsychiatric patient assessment and the use of all treatment modalities, both psychotherapeutic and pharmacologic, in elderly patients. The contributors discuss the treatment of disorders in all clinical settings: inpatient, outpatient, emergency, primary care, assisted living and long-term care. The book includes case studies and personal accounts by patients and care providers. Appendices provide drug information and list additional resources.

Weight Bias: Nature, Consequences and Remedies
by Kelly D. Brownell, Ph.D., professor of psychology and epidemiology, Rebecca M. Puhl, Ph.D., Marlene B. Schwartz, Ph.D., and Leslie Rudd (The Guilford Press) The authors explore the nature, causes and consequences of weight bias and present a range of approaches to combat it. They discuss topics including the barriers facing obese adults and children in health care, work and school settings; theories on how stigma develops; the impact on self-esteem and health; and strategies for reducing prejudice and bringing about systemic change.

The descriptions are based on information from the publishers.

Send notices of new books by alumni and faculty to Cheryl Violante, Yale Medicine, 300 George Street, Suite 773, New Haven, CT 06511, or via e-mail to cheryl.violante@yale.edu.

In circulation

A digital treasure trove

James D. Jamieson, M.D., Ph.D., professor of cell biology, knew that he had a piece of history in his closet: lantern slides made by the pioneering cell biologist George E. Palade, M.D., and colleagues. Those images of cells seen through the electron microscope had laid the groundwork for Palade’s 1974 Nobel Prize in physiology or medicine. “Palade and his people really formulated, invented and provided the information that started the field of cell biology in the 1940s,” said Jamieson, who did his doctoral work at Rockefeller University with Palade and came with him to Yale.

Jamieson knew that his mentor, who was at Yale from 1973 until 1990, wanted the images to be available to students and scientists around the world. And so Jamieson cleaned the 3.25- by 4-inch glass slides, which Palade left at Yale. Jamieson then digitally scanned 191 slides. Arthur R. Belanger, M.S., project manager of academic media and technology, indexed the slides and placed them on the website of the Cushing/Whitney Medical Library.

The Palade slides are among several digitized collections now available on the website. Other collections include engravings of historic figures and oil portraits of Chinese patients with tumors and other deformities from the mid19th century. The digital collection will expand, said Daniel M. Dollar, M.L.S., associate director of collection development. Palade’s slides helped biologists to relate what they were learning about cell morphology through the electron microscope with what was being discovered about cellular biochemistry through cell fractionation, the process of separating a cell into its distinct parts with a centrifuge.

This holistic understanding of cell function and structure provides the foundation for contemporary understanding of disease processes, because, Jamieson said, “you need to know what’s going on in the normal cell before you begin to figure out what’s going on in the diseased cell.”

The Medical Digital Library can be accessed at http:// www. med.yale.edu/library/subjects/digital.html. An exhibit by the Yale Medical Historical Library charting the life of pioneering neurosurgeon Harvey Cushing, M.D., is now available online at http://www.med.yale.edu/library/historical/cushing/.

—Cathy Shufro

In Circulation focuses on activities at the Cushing/Whitney Medical Library. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.



Levy		Stickgold



Nuland		Cullen

On campus

Physician-assisted suicide is the wrong solution

At a time when life is devalued, when people are killed over necklaces or iPods, physician-assisted suicide ill serves patients, physicians and society, said Michael H. Levy, M.D., Ph.D., during a talk at internal medicine grand rounds in January.

“If we look at physician-assisted suicide as an act of hastening death,” said Levy, vice chair of the Department of Medical Oncology at the Fox Chase Cancer Center in Philadelphia, “then it is an act of harm. … Do we really need to kill the patient to kill the pain?”

Levy said physician-assisted suicide violates key tenets of medical ethics; erodes trust in health professionals; and diminishes what he called “the miracle of life.” It also denies a patient’s loved ones the chance to provide care at the end of life. If legitimized, he said, it could force doctors to provide a service they oppose. And, he continued, it could stifle the search for alternate ways to relieve suffering.

“I think the risk to society far outweighs the benefits,” Levy said.

—John Curtis

Is sleep no more than a cure for sleepiness?

In 1989, when scientists kept rats from sleeping, the rats started to die by the 11th day. By the 32nd day, they were all dead. “We are still clueless as to why the rats died,” said Robert Stickgold, Ph.D., associate professor of psychiatry at Harvard Medical School and an expert on sleep, speaking at internal medicine grand rounds in November. “It happens in rats,” he continued. “It happens in humans.”

For 2,000 years we have understood other basic drives, such as hunger and sex, he said, but the need for sleep remains a mystery. Among early candidates for its apparent benefits, said Stickgold, were restoration and recovery, energy conservation and avoidance of nocturnal predators. “When you try to parse those out,” Stickgold said, “none of those make sense. You end up back at the point that sleep is to cure sleepiness.”

Yet more recent studies have confirmed that a good night’s sleep confers numerous benefits. Without it, the immune system produces fewer antibodies to fight infection. And it is during sleep that the brain consolidates the day’s memories and learning.

“It does matter how much sleep you get,” Stickgold said.

—J.C.

The teachings of Maimonides and a moral imperative

The 12th-century physician Maimonides, who lived in Spain and Egypt, achieved fame as a rabbi and philosopher yet helped to establish a moral imperative that guides medicine to this day: the obligation to make every effort to heal the patient.

Although best known for his Guide for the Perplexed, which proposed ways to reconcile religion and science, the scholar also proposed an alternative to the prevailing Christian view of a doctor’s role, said Sherwin B. Nuland, M.D. ’55, HS ’61, clinical professor of surgery and author of a biography of Maimonides. In a December talk, Nuland told members of the Interdisciplinary Center for Bioethics that Maimonides saw medical care not as a prayer but as “something physical that needs to be done.” Healing remained linked to faith, nonetheless, because renewed health would allow the patient to resume his study of God.

As a physician, Maimonides believed that “you are to make any sacrifice other than another human life to save someone you can possibly save,” Nuland said. “There is no credit to be given to a physician for doing his work. It is an obligation.”

—C.S.

Environment and society: which determines health risks?

A two-story house has peeling paint and no yard. Behind it loom industrial smokestacks. Mark R. Cullen, M.D. ’76, HS ’79, professor of medicine and of epidemiology and public health, and director of the Yale Occupational and Environmental Medicine Program at the School of Medicine, used a photograph to frame a lecture in March at the School of Forestry & Environmental Studies. Do children in that house face health risks because of toxins from factories and lead from peeling paint or because they live in an overcrowded, high-crime neighborhood with a crummy school and no recreational facilities?

Environmental epidemiologists focus on the physical environment, while social epidemiologists look at patterns of psychological and social stress. Both inquiries, Cullen said, are too narrow. “Neither side explains it all.” Historically, however, the two fields haven’t shared information. Cullen says researchers need to “deal with their agendas in tandem,” because that’s the only way to get a full understanding of a population’s health status. That knowledge can lead to the creation of such initiatives as more recreational space on the street or tougher air pollution standards, which will better address health issues.

—Jennifer Kaylin


			Originally published in Yale Medicine, Spring 2007. Copyright © 2007 Yale University School of Medicine. All rights reserved.