When Breath Becomes Air

They say a doctor makes the worst patient, and like most cliches, it’s probably true.  But a new book reveals the doctor-as-patient experience also can instill an invaluable understanding of human suffering, which is a gift to patients and in this case, readers.  

When Breath Becomes Air is written by Paul Kalanithi, a neurosurgeon/neuroscientist and writer, whose only book is a bestselling memoir of life in the shadow of cancer.  The title is drawn from a favorite poem of the author about the ephemeral sweetness of living:  “You that seek what life is in death, Now find it air that once was breath...”

The book opens with an unforgettable description of a young doctor looking at a series of scans and discerning the massive, ghostly tumors that have taken up residence in human lungs. Only after describing the picture and deadly diagnosis does the author reveal that the scans are his own.

Throughout the course of the book, the reader witnesses the maturation of a brilliant young man forced to live the fullness of life in an abbreviated timeframe.  After he graduates cum laude from Yale School of Medicine, Kalanithi returns to his alma mater, Stanford University, to complete a residency in neurological surgery and a postdoctoral fellowship in neuroscience.  Just two years short of completing his training and a heartbeat away from the life of his dreams, Kalanithi falls victim to a disease that he has already wrestled with many times in his career.

“I had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking,” he writes. Yet, after years of study and striving to know death, the ultimate understanding comes through his own experience.  

After describing a patient with a traumatic brain injury, Kalanithi realizes that he has not been with patients in their pivotal moments, but only at those moments.  In medical school, he writes, he had become inured to human suffering.  In this, Kalanithi raises a broader question: whether this is the problem with modern healthcare: the science and learning is divorced from the essential humanity of medicine.

One of the remarkable things about this book is that Kalanithi never asks, why me?  At 36, he’s a runner and bicyclist who likes to explore California’s Central Coast with his wife and friends.  The fact that he is diagnosed with lung cancer (which is extremely rare for someone of his age in the first place) underscores the importance of ongoing research in an area that many see as explored, understood.

When he receives his diagnosis, his immediate response is to quit surgery, to spend time with his wife, Lucy, to sit quietly and enjoy what’s left of his life.  But his doctor has different plans for him.  She advises him to decide what’s most important, and to spend his time doing that.  She refuses to give him a prognosis, although at first that’s what Kalanithi expects.

In the end, he understands her reasons.  He sees that the choice is his; that the existential authority that people proffer on doctors actually belongs to the patient.

“Shouldn’t terminal illness be the perfect gift to the young man who had wanted to understand death?” he asks.  “Who would I be? and for how long?”  

Ultimately he decides to return to the OR. Why? “Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I’m still living.”

His book, left unfinished when he passed away in March 2015, was completed and published by Lucy in early 2016.  “When Breath Becomes Air is, in a sense, unfinished, derailed by Paul’s rapid decline, but that is an essential component of its truth,” she writes in the epilogue.

Kalanithi’s choice was to be doctor, surgeon, husband.  He and Lucy also decide to have a child, who’s just six months old when he passes away.  His decision to also be a writer was perhaps his greatest gift to us.