Letter From the Editor: When Breath Becomes Air

Clinical Advances in Hematology & Oncology
Volume 14, Issue 6, June 2016

Bruce D. Cheson, MD

For my most recent book club meeting, I brought not only two 90-plus–point wines (Kung Fu Girl, a delightful Washington State Riesling, and a 2011 Poggio al Tufo Rompicollo from Maremma, Italy) and the cheese, but also a large box of Kleenex. The book we were discussing was When Breath Becomes Air, a beautifully written memoir by Paul Kalanithi, a brilliant neurosurgical resident whose life was obliterated by the development of widely metastatic lung cancer. As he put it, “the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.” My book group as a whole felt this book to be the best among the recent offerings, and the read a valuable experience.

We divided the narrative into 3 basic parts. The first phase was his prelude to medicine. Before Kalanithi decided to study medicine, his focus was more literary. Despite coming from a family of doctors, he “knew with certainty” that he “would never be a doctor.” He loved his life of freedom, unlike that of his ever-absent physician father. When he went to Stanford, his goal was not to study medicine, but to understand what made life meaningful. He took courses in literature as well as in biology and neurosciences, followed by a master’s degree in English literature. Eventually, he realized that his persistent interest in neurosciences didn’t quite fit with the rest of his plan. So, off to medical school he went, which sharpened his understanding of the relationship between meaning, life, and death.

The second phase was his total dedication to his chosen profession: the intense and unforgiving subspecialty of neurosurgery. He distinguished between those physicians who had a “job”—who decided on their specialty based on the lifestyle it afforded—and those who had a “calling.” He described the long hours and the endless studying. At one point, he became inured to the death surrounding him. When he realized this, he recoiled, recognizing that what was most important was his responsibility to establish relationships with—and thereby further help—his patients, despite the emotional costs. His surgical and personal skills launched him on a trajectory that included both surgery and research, and he was made chief resident.

The third phase was his illness. At first he ignored the signs, as many doctors do. The pain and weight loss were attributed to stress and long hours, until finally the sentence of death was spoken. Kalanithi went through a series of treatments, and his disease was eventually put into remission with a targeted agent because his tumor carried the requisite mutation. He now had hope for years of life and even, albeit briefly, began to consider a job offer with millions of dollars in research money and much more responsibility. Then came the inevitable relapse and his inexorable decline. After much consideration, he and his wife decided to go through with having a baby with stored sperm. At the end, all three were nestled together in his hospital bed as he peacefully died.

There was much to discuss about this book, beyond the stunning prose. What would we do if confronted by his situation? A few said that they would continue working, although most felt they would give up practicing medicine and just have fun. We talked about Kalanithi’s changing role from physician to patient. We debated the decision to have a child; she was a gift to share with his wife, but was it fair to his wife to raise her alone? Was it fair to the girl to be raised without a father? But mostly, we discussed the strength with which Kalanithi faced his fate. There was a notable absence of anger and blame. He used his impending death to go full circle, to gain a better understanding of life. His strength persevered throughout the various stages of his illness, exemplified by the recurring words from Samuel Beckett: “I can’t go on. I’ll go on.”

I could end this note at this point, but I would be ignoring what, for me, was perhaps the most moving part of the book: the epilogue written by his wife Lucy. She described what writing the book meant to Paul and to her, as well as her sense of loss in missing their life and future. Most importantly, she recalled his strength in facing death with as much honesty and integrity as he could.

Until next month…

Bruce D. Cheson, MD