The making of a physician

A Surgeon's Reflections on Mortality

By Pauline W. Chen

Knopf. 288 pp. $23.95

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Pauline W. Chen starts her memoir,

Final Exam: A Surgeon's Reflections on Mortality

, where any medical student's training starts, whether she ends up a dermatologist or brain surgeon: the dissection of a cadaver.

"By the time my lab partners and I finally uncovered our cadaver's face, we had spent every day for the previous ten weeks in and out of her body," Chen writes. "A clear plastic bag encircled her head and white muslin cloth, moistened with formaldehyde, clung to the contours that were her eyes, nose, and mouth. I lifted the cloth slowly, starting at the corner that covered her chin. Somehow I felt that seeing her face - her eyes, her lips, and her final expression - would confirm the lift I had tried to re-create in my mind."

Final Exam is not for the faint of heart - that passage is one of the least raw of the medical scenes in the book. Chen is as masterful with her writing as we can assume she is as a surgeon, and Final Exam shows in full her experiences while training to become a transplant surgeon. Her words are carefully chosen and exact, as if she's taken the discrete parts of her experiences in medicine and stitched them together to form a functioning whole - as she would to form a functioning human body. So you'd expect a little blood and guts along the way.

The key struggle for Chen is the fine line she walks in training to become skilled and efficient doctor and in remembering that she's working on human beings - and that she, too, is one. It's not a task Chen handled well in her first years of medicine, which make up the bulk of Final Exam.

Chen, who trained at Yale University, the National Cancer Institute, and UCLA, describes the life of a medical student, intern and resident as it was before hospitals started limiting how many hours interns could work a week (though the grind is still a grind: Intern hours worked have only been cut to 80 a week). Through Chen's perspective, we see how difficult the training can be. After Chen and her colleagues are told the best way to work with patients is to imagine being in their shoes, she writes: "As an intern and resident, I worked fourteen-hour days and was awake through every other or every third night. I had no time to stand in someone else's shoes; I could barely remember what my shoes were like."

Most of Final Exam shows Chen stuck in the same mental place: She's all surgeon-in-training, with that conflict between who she thinks a doctor should be and who she in fact has become nagging at her like a tickle in the back of her throat. It's a tunneled view, and only after Chen harvests the organs from someone who looks very much like herself, and starts to write about her experiences, does she break and, we assume, start to heal and reconcile being a doctor with making a living.

Final Exam could be seen in a lot of ways: as an expose of medical training; as commentary on end-of-life care; as one person's story from the trenches; as Chen's frustration over how she was trained. TV shows and movies have taken a shot at these, but does anyone really believe that ER or even Grey's Anatomy mimic what is real? That the drama between the team is more important than the people on the hospital bed?

Not every doctor will identify with Chen's experiences, but she writes about enough supporting characters, from the student who never made it through gross anatomy to a seemingly stalwart resident who loses it, that she gives the lay reader a keyhole view into a world rarely glimpsed by outsiders, a world that may one day save or end one's life. It's well worth a look.