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When Breath Becomes Air by Paul Kalanithi, Published by Corcovado, 2016

written by Linda Yau, M.D., F.A.C.P.
on Wednesday, 6th July ,2016

My good friend from medical school forwarded me an article called Before I Go published in the Spring 2015 Stanford Medicine magazine.   It was written so beautifully by a young neurosurgeon that it made me tear up.  Dr. Kalanithi majored in English and biology at Stanford and then got a master’s in English literature before attending Yale School of Medicine.  This article is a small excerpt from his book which he wrote faithfully while undergoing chemotherapy for metastatic lung cancer.  He was 36 years old.  The article captures the time warp he feels in different places of his life:  the operating room, neurosurgical training, undergoing cancer therapy and being a father to a newborn baby girl.

He openly describes the heart wrenching experience that every doctor fears since learning about disease as a medical student.  In the opening paragraph of the book, he describes looking at his own CT scan which reveals numerous tumors in the lungs, liver and spine.  He then relays the sad interactions between himself and his wife, Lucy, whom he met in medical school, and is a practicing internist, revealing some of the marital tensions that occurred between them as a result of the long hours of neurosurgical training.  This rift occurs as symptoms of cough, weight loss, searing back pain and weakness culminate in medical testing and the diagnosis of inoperable lung cancer.  Part I of the book is entitled In Perfect Health I Begin.  He describes the beginning of his academic career, explaining how his mother was the guiding force in his education while growing up in the remote city of Kingman, Arizona.  Because he is the son of a physician who is always at work, like many doctor’s children, he vows not to go into medicine.  He describes a colorful childhood in the desert, surrounded by scorpions, rattlesnakes and spiders.  His mother forces him to read 1984 from a college preparatory reading list when he is 10, which is the start of his lifelong love of literature.  His quest for what makes the human life meaningful framed his college studies at Stanford.  He recounts many memories that influenced his further study into the human brain and his decision to apply to medical school and then pursue neurosurgical training. 

In retrospect, Dr. Kalanithi remembers being influenced by Shep Nuland’s book How We Die as well as his experiences in his clinical rotations as a medical student.  “The first birth I witnessed was also the first death.”  This foreshadows the juxtaposition of his own process of dying with the birth of his daughter 2 weeks after he is released from the hospital.  He writes about how his decision to go into neurosurgery is influenced by the clinical interactions he sees with the attending surgeons and patients.  His lifelong interest in philosophy, literature and biology intersects in studying the human brain. He recalls the first of his patients who dies as well as many others who taught him lessons.  He begins to see the difficulties of always putting patients above one’s own needs to eat, sleep and function while in residency. 

Part II entitled Cease Not Til Death begins in the hospital where he and his wife lie together in the bed crying after reviewing images of his own CT scan.  Once again, Dr. Kalanithi’s prose conjures up striking images for the reader to ponder.  “My carefully planned and hard-won future no longer existed.  Death, so familiar to me in my work, was now paying a personal visit.  Here we were, finally face-to-face, and yet nothing about it seemed recognizable.  Standing at the crossroads where I should have been able to see and follow the footsteps of the countless patients I had treated over the years, I saw instead only a blank, harsh, vacant, gleaming white desert, as if a sandstorm had erased all trace of familiarity.”  The existential thought processes which he had to talk through with his wife and his oncologist reveal the difficulties in health care decision making when life expectancy is difficult to predict.  He describes the decision on whether or not to become parents, and how to make those decisions in the face of his mortality.  His love of literature and reading helps him to find meaning during this difficult time.  In the end, his wife Lucy Kalanithi, an internist, wrote the epilogue to the book.  She also possesses wonderful writing skills and is carrying on her husband’s legacy by promoting the book across the country.

As Abraham Verghese states in the prologue to the book:  “Be ready.  Be seated.  See what courage looks like.  See how brave it is to reveal yourself in this way.  But above all, see what it is to still live, to profoundly influence the lives of others after you are gone, by your words.”

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