American medical education produces doctors whose superpower is a wondrous agility on standardized tests. We have crawled our way past the PSAT, the SAT, the MCATs, and the National Board of Medical Examiners Parts 1, 2, and 3, till finally we vanquish our specialty certification.
There is only one flaw: When we bump up against a real-life problem, we can be horribly dimwitted. So, when challenged by the biggest problem of all—death—we do what we know best: design yet another program of study and qualification. First 1) comes problem identification; 2) then a curriculum; 3) a course to attend; 4) national guidelines; and finally 5) a multiple-choice test to reach the promised land 6) of certification.
The medical world's optimistic belief in this kind of remediation is the premise underlying recent books by two big-hearted doctors, Final Exam by Pauline Chen, and The Lonely Patient by Michael Stein. For these physicians, there is no challenge that can't be solved by a medical-school curriculum that offers extra instruction in soul-searching. Structured as half memoir, half self-help manifesto, the books discuss illness and dying from a doctor's perspective: the first time the authors saw a dead person (awful to witness); encountered a cadaver (strangely engrossing); faced the illness of a close friend or family member (extra awful); and broke the bad news to patients (don't ask). Chen in particular writes quiet, clear-eyed prose—plus she loves, really loves the innards of people (she waxes poetic about fascial planes and tenacious dermal layers).
But when she leaves the descriptive world for the soapbox, the charm and delicacy of her medical coming-of-age story turns sour. She becomes hellbent (as does Stein) on slapping around the medical profession because we don't deal with the nonscience side of medicine as well as we should. We don't listen; we don't sympathize; we don't see the real person behind the disease; we are too caught up in our own importance and lifelong hurry to stop and take in the big picture. Our fancy tests and fancier machines have distanced us from the core of professional responsibilities carried out so admirably by yesteryear's country doctor, the one who would hold your hand and look you in the eye and speak the truth. And worst of all, we are relieved to have taken ourselves off the hook as we zip around with our cool gadgets.
Chen's plan for a cure follows the six-step program above—a "final exam," indeed. Though less pointed, Stein too laments the dominance of the heartless, mechanical doctor who has abandoned his role as healer for the seductions of the high tech. Despite the term-paper thoroughness of the books—Stein quotes everyone from Milton to Harold Brodkey—both doctors overlook a crucial fact. Serious illness is awful, death unimaginably worse, and a doctor's performance can do almost nothing to change this.
In a central moment in Chen's book, a friend's father dies a horrible death. The friend breaks into tears, in Chen's view because the doctors did not talk about the father's imminent death with her or her family. I would quibble mightily with this interpretation. Isn't it more likely that Chen's friend cried because her father had died? Yes, the physician fell far short of one's hopes in such a situation. But Chen's certainty that this bungling significantly added to, rather than confused, her friend's grief hands doctors far too much power. In a way, both authors inadvertently return to the old-school doctor-as-god point of view. Only we are mighty enough to soften Shakespeare's 1,000 blows that flesh is heir to; only we can ease the pain of death.
In fact, doctors aren't bad at handling the details of dying. We know how to ease pain, promote comfort, and arrange the medical particulars. But we are disasters when it comes to death itself, just like the rest of the human species. (Morticians often have the same problem.) I admire Chen's and Stein's pep-club optimism, but they might have integrated Ernest Becker's seminal Denial of Death into their discussions. Becker's basic point is that all of human behavior can be traced to our inability to accept our own mortality. Cowards that we are, we not only refuse to consider our own inevitable death, but our patients', too: We duck the tough discussions, flinch and flutter and order another test, and finally leave it to a (usually much younger) colleague to sit down with the family. We don't slink away because we are bad people; we slink away because we are people.
Becker also is curiously absent from How We Die, Sherwin Nuland's examination of death—a work that has made him the godfather of death books. Yet despite the omission, Nuland succeeds where Chen and Stein fall short. Here's my explanation: Nuland was not young when he wrote How We Die, and unlike Chen and Stein, he was not trying to reform American health care. Rather, he wrote with the panic and urgency of someone who sensed his own upcoming deadline, giving us a kind of What To Expect When You're Expecting To Die. He admits to doctors' yellow streak, pointing out that medicine is "more likely to attract people with high personal anxieties about dying." We are the ones seduced by the irrational belief that knowing about a disease will prevent it. Instead of a quick fix for our weaknesses, Nuland envisions patients making the big decisions with their loved ones, informed and advised—not directed—by their doctors. In other words, he reduces doctors to their proper supporting role. (Nuland also has a new book out about aging.)
I agree with Nuland that doctors' failure to deal well with their patients' deaths is not a bad habit that can be corrected by medical-school remediation. Doctors and patients would be better served if we stopped sophomorically pursuing the "good death" reassuringly reducing the end of life to another commodity subject to adjustment and negotiation. Instead, we should do what we can to make the dying and those who survive a tiny bit more comfortable when the time comes. As doctors, we should ease pain; as humans interacting with other humans, we should console those who are anguished as best we can because it is the right thing to do, not the professionally optimal approach. This modest goal is all we can hope to accomplish—but still seldom do.