Departing lessons (book excerpt: Final Exam)

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The dissection of the human body had fascinated me since I was 7 years old. I had some idea back then that I might want to become a doctor. At the time my Agong [maternal grandfather] had just been diagnosed with a brain tumor, and my mother took my younger sister and me back to Taiwan for the summer to be with him. The diagnosis, the operation, and the neurologic deficits resulting from the removal of a part of my grandfather's brain would eventually color the rest of my grandparents' lives together. Nonetheless, at the time I was enthralled by the way his neurosurgeon comforted my grandmother and family. He was a big, bald Taiwanese man, with a round face, hands like bear paws, and a demeanor that was at once humble and confident. When he came out to the waiting room to an audience of anxious family members, his words -- "I got it all out" -- fell on us like a great light from the heavens. That experience convinced me that medicine was the work of gods.

An aunt who was in medical school at the time heard about my interest and offered to take me to her anatomy lab. I was fascinated by the idea that there might be secrets about life and death lurking there. At that age I already had come to believe that dissection was the greatest event that separated physicians from the rest of us. To be able to stomach such an experience, I thought, would prove my mettle, and to sneak a peek into the inner workings of a body -- a dead body, no less -- would put me in a league beyond any other second-grader I knew. My parents, however, quickly vetoed the idea, fearing that such a close-up and possibly gruesome experience might scar me permanently.

Like all initiation rites, the dissection of the human cadaver poses several obstacles to the neophyte. First, the new medical student has to memorize a vast array of anatomical facts. Such rote memorization can be mind-numbingly dull, and the overwhelming amount of information makes the task seem Sisyphean. One of my college mentors, a brilliant psychiatrist and anthropologist, counseled me before I started. He had completed medical school some 20 years earlier. "It's like memorizing a telephone book," he said. "You just have to get through it."

Memorization, however, is probably the easiest obstacle to surmount, and it has until recently been the only focus of medical schools. The more difficult, and often unspoken, obstacle for medical students is accepting death and the violation of the human body. In the human anatomy course, cadavers are laid before fledgling physicians, and the familiarity of their form reminds us that each lived lives not unlike our own. In the human anatomy course, cadavers are laid before fledgling physicians, and the familiarity of their form reminds us that each lived lives not unlike our own. For those of us who wince from simple paper cuts, running a scalpel against skin and definitively dividing the essential structures that once powered a fellow human are acts that require a leap of faith. While all aspiring physicians fully expect to perform a human cadaver dissection in medical school, the expectation hardly tempers the brutal reality.

Aspiring physicians face death directly in the form of the cadaver. And then they tear it apart. Each detail of the cadaver -- every bone, nerve, blood vessel, and muscle -- passes from the world of the unknown into the realm of the familiar. Every cavity is probed, groove explored, and crevice pulled apart. In knowing the cadaver in such intimate detail, we believe that we are acquiring the knowledge to overcome death.

To complete the initiation rite successfully, however, we need to learn to separate our emotional self from our scientific self; we must view this dead human body not as "one of us" but as "one of them," a medical case to be understood but not embraced. This ability to distance the self, I was to learn later, would be called upon again and again in my medical training. It was as if such separation would provide me with a greater sense of objectivity, a modicum of strength, and thus an enhanced ability to care for my patients. But this first lesson in disengaging from the personal was the most radical: It required suppressing that fundamental and very human fear of death.

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The next excerpt details how a doctor stayed with a woman whose husband was dying in the ICU.

The woman now stood stiffly by the unit secretary's desk, her eyes red and puffy and her lips drawn tightly closed. I tried to smile, not sure how to greet a woman who was about to watch her lifelong partner die. All I could think of saying was "I'm sorry." She nodded in response and looked over toward her husband's room.

I felt myself pulling away. I could not convince myself that the woman would be happier alone with her dying husband. But there was little I could do to stop; it was as if the familiar ritual had already been set in motion. I took a step back and fell hard against a chair, having tripped over my own feet.

My attending surgeon took the woman's hand and quietly explained what was happening. Her mouth opened and she began sobbing. He gently led her to the room, where I saw her jerk forward, crumpling in front of her husband's bed. The surgeon then walked back toward me, but instead of leaving the woman in the room alone, he closed the curtains around the three of them.

I hung back for a few minutes but became curious when the surgeon did not step out. What was he doing in there? Why didn't he leave her, as we always did?

I peeked in. Inside, the woman was still sobbing, but she was standing with her hand in her husband's. The surgeon stood next to her and whispered something; the woman nodded and her sobs subsided. Her shoulders relaxed and her breathing became more regular. The surgeon whispered again, pointing to the monitors and to the patient's chest and then gently putting his hand on the patient's arm. He was, I thought, explaining how life leaves the body -- the last contractions of the heart, the irregular breaths, the final comfort of her presence. The woman nodded and began crying softly and stroking her husband's arm.

I wanted to join them but could not bring myself to do so. I pulled the curtains closed and went back to the nursing station to wait.

Thirty minutes passed before the surgeon stepped out. Soon after, the patient's wife appeared; her husband had died. She thanked us, smiled weakly, and walked out of the ICU.

She sent me a note a couple of weeks after her husband died. The stationery was cream-colored with slate-blue borders, and her handwriting had long sweeping tails that crisscrossed over the note. She wrote that although her husband did not die at home, as she had always hoped, he had died a dignified and peaceful death. "And that," she wrote, "was all we really wanted."

I kept that note with me for a long time afterward as a reminder of what doctors could do. And long after I had filed it away in my "Patient Correspondence" file, I would reach into my white coat pockets as if the note were still there and fall back on my memories of that morning as if they could encourage me forward.

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 the 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.

I never discussed that morning's events or the contents of the woman's note with my former attending. I never revealed how his deviation from the norm affected me. I never told him that it was as if a shade had lifted ever so slightly, letting in the first rays of light, and that from that moment on, I would believe that I could do something more than cure.