When Breath Becomes Air

Take a deep breath, in and out. Now imagine that breath was your last.

Hello from snowy Boston. I returned from India yesterday. On the long airplane flight I read Paul Kalanithi’s posthumous memoir, “When Breath Becomes Air.” His book has received a number of glowing reviews, for example in the New York Times and the Boston Globe.

The first time I heard of Kalanithi was in 2014 when I read his op-ed in the New York Times, “How Long Have I Got Left?” My wife and I had driven from Atlanta to Savannah for a brief vacation. We were camping out at Motel 6 and Kalanithi’s story left me breathless. His predicament was so tragic and he had so many insights into life and death.

A few reflections on Kalanithi’s unforgettable, life-affirming memoir are below. As a warning, there are many spoilers, so I suggest you read the book before going on to my blog post:

  • His childhood
    • Parts of Kalanithi’s book remind me of the late Oliver Sacks’s focus on the natural world. For instance, his descriptions of spiders in the Arizona desert (page 22).
    • The poor quality public schools in rural Arizona and his mother’s quest to ensure that her children received an excellent education were also memorable (page 25-27). His mother achieved her goal, as Kalanithi went on to Stanford and Yale. 
    • His father was a physician and was frequently “absent” (page 20-21).
    • This made me realize the importance of not being a workaholic. There are many things in life that are more important than medicine (i.e. family).
  • Gross anatomy
    • Kalanithi wrote that cadaver dissection represents the transition into the “callous, arrogant doctor” (page 44).
    • I agree. There needs to be much more education about death and dying during medical school.
    • For example, I think first-year medical students should have a required “Hospice/Palliative Care 101” course which runs concurrently with Gross Anatomy.
  • Relationship with his wife
    • Neurosurgery residency was a huge stressor for Kalanithi’s marriage (page 10-11).
    • I wonder how many other relationships suffered because of the long hours of medical training. Probably the majority.
  • Doctor-as-patient
    • This theme has been explored poignantly by Kate Granger (The Other Side), Oliver Sacks (Gratitude),  and many other physician-writers.
    • Yet Kalanithi’s book is easily the best I’ve ever read about a doctor becoming a patient.
    • One day Kalanithi was healthy, and the next day the “future I had imagined” just “evaporated” when he was diagnosed with lung cancer (page 16).
    • Kalanithi’s book should be required reading for all pre-medical and medical students.
  • Death
    • As background, I’ve had a longstanding interest in end-of-life care. My mother is a retired hospice nurse. During college, I took a course on literature and medicine by Arnold Weinstein and another on the music of death by David Josephson. For a summer, I did research with Joan Teno on palliative care. I completed a month-long rotation in hospice medicine during my residency and have taken care of many dying patients during my medical career, in Philadelphia, San Diego, Boston, Guatemala, Botswana, and Mozambique.
    • I believe denial and fear of death are powerful forces in our daily lives. They drive our behavior in ways we rarely realize.
    • Kalanithi’s reaction to his terminal diagnosis was poignant. There’s no reason for me to try to summarize it. For that, you need to read his book.
    • While Kalanithi was reassured by literature (T.S. Eliot and Baron Brooke Fulke Greville, for example) and his Christian faith, this book makes me recall the Mozart RequiemVerdi Requiem, and my favorite, the Faure Requiem. Literature, music, and religion, they all help us cope with the dying process.
  • Physician suicide
    • One of Kalanithi’s fellow medical students Mari, was clearly mistreated by being expected to participate in a 9-hour surgery after being awake all night (P. 67).
    • One of his neurosurgery chief residents got a divorce (page 73).
    • Another surgery resident, Jeff, jumped off a building (page 113).
    • Jeff’s suicide made me recall the classic novel, The House of God, where Potts is mistreated and jumps off a building, and The Tennis Partner, where the main character commits suicide due to depression and drugs.
    • JAMA recently had a series about depression in medicine.
    • In this memoir, I think Kalanithi was too kind to our inhumane medical training system. Frankly, medical school and residency leads to many young people becoming depressed and killing themselves. Something needs to change on how we treat vulnerable medical students and residents.
  • Relationship with his oncologist
    • Kalanithi’s oncologist’s unwillingness to speak openly about his impending death made him angry (page 122-123).
    • However, as his disease progressed, he began to turn his medical care over to her (page 182) and his family.
    • This transition is understandable, as the doctor-as-patient gradually loses control.
  • Preventable traumatic brain injury
    • Paul saw all sorts of terrible deaths, primarily due to car accidents and shootings (Page 78).
    • I am left wondering if there are neurosurgeons who are willing to speak out about the dreadful burden of car and gun violence.
    • Public health advocates try to push for safer roads and communities but are usually dismissed. Few people want to pay attention to (or pay for) prevention.
    • If a prominent neurosurgeon-journalist like Sanjay Gupta were to come out strongly against the dangers of cars and guns, that could have a huge effect on the American consciousness.
  • “Careerism” and medicine
    • Paul describes radiology and dermatology as “less demanding” fields than his, neurosurgery (Page 68).
    • Society needs to pay primary care doctors more than subspecialists and ensure that they have adequate time with patients.
    • Otherwise we will not achieve the primary care workforce we desperately need.
  • White coats
    • Kalanithi wrote that he was “so authoratitive in a surgeon’s white coat” but “so meek in a patient’s gown” (Page 5).
    • “Brad” was the example of an egotistical doctor (P. 185) who denied Kalanithi a medication he very much needed.
    • In my opinion, the power dynamic of the white coat needs to be broken down.
    • That would start if medical schools revamp the white coat ceremony by getting rid of white coats.
  • Relationship with his daughter, Cady
    • My son Joseph is only a few months older than his daughter Cady, so this part of the book was extremely powerful.
    • When do our children start having memories?
    • What will our children remember of us after we are gone?
  • The sensation of time
    • One of my best friends from high school, Luke Sink, died of undiagnosed Ehlers-Danlos syndrome while he was a sophomore in college.
    • His family gave his friends clocks with a plaque saying “Time is Precious.”
    • I have always treasured that clock.
    • Time really is precious.
  • His urgency to write
    • When Kalanithi was dying, he wanted desperately to finish his book.
    • The urge to write, to leave something behind for Cady, was very powerful.
  • His faith
    • I wrote most of this book review in India, which is a particularly spiritual country.
    • Faith is often at odds with science, and agnosticism and atheism is common in physicians.
    • Many are reluctant to talk about faith with their patients yet I think this is a crucial area that needs to be addressed.

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Thanks so much for visiting my website! Writing and reading blog posts does take time and we all know that time is in short supply. You and I will both get much more out of this blog if it leads to dialogue. If you found my post useful and wouldn’t mind leaving a brief comment or sharing on social media, I would be grateful. Or if you’re shy about Tweeting but are willing to email me a comment that I can post anonymously or send an anonymous Surveymonkey, that would be great. My posts are generally written quickly, so if you find any factual or grammatical errors, please do let me know. Best regards, Philip Lederer

7 thoughts on “When Breath Becomes Air

  1. One of the most beautifully written books I’ve ever read – your notes on his book are excellent. I was diagnosed/treated for cancer 3 years ago (surgery/chemo/ongoing treatment) and so many parts of his story hit home for me, but my heart breaks for all those who are so brilliant and taken so young – and for anyone suffering through illness. Every day is a gift, enjoy your family and friends and moments together.

  2. Hello!
    I really enjoyed reading your blog on the Courageous Paul Kalanithi’s ‘When Breath becomes air’. My sister is a Neurosurgery Nurse and worked some years with him.
    As I had lived in North Carolina she would keep me informed on his progress and often express to me how special Paul was to a lot of people!
    He was and is an inspiration to many people. Thank you for writting this blog as it keeps his memory alive and tells of his great courage! Rebecca.

  3. I’m still angry about Brad’s treatment or should I say, lack of treatment for Paul. What a horrible decision that quickly dominoed into massive suffering. I wanted to know if Emma ever held him accountable. I would love to know Brad’s reaction to this book.

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