Chasing Chapters \\ When Breath Becomes Air (Paul Kalanithi) + the fears of a doctor-turned-patient + mortality

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Chasing Chapters is a series devoted to reviewing (and quoting excessively from) books I’ve enjoyed or been inspired by, to hopefully give you new recommendations for your reading list.

I admit I was terribly late to the ‘reading When Breath Becomes Air’ party, but better late than never. I avoided reading it for years because med school groupies oversold it as a book about a dying neurosurgeon (Dr Paul Kalinithi) who was devoted to his craft till the very end, and somehow managed to juggle family & chemotherapy on top of all that.

But they missed the point. When Breath Becomes Air is a final love letter from a dying father to his infant daughter. If you don’t believe me, just read this excerpt from the last page of his story and try not to cry:

There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past.

That message is simple: When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

a quick summary

Writing When Breath Becomes Air in the final year of his life, we’re taken through Paul Kalanithi’s formative years, through his career as a perfectionistic neurosurgeon, marriage/fatherhood, and how he came to terms with his own mortality after receiving a diagnosis of terminal cancer.

Born to an immigrant doctor father and a mother who was determined to instill a spirit of curiousity in her 3 sons, he was highly driven to succeed and make good of his life. After completing degrees in literature and human biology (at Stanford & Cambridge), while searching for the meaning of life, he stumbled into his lifelong calling to be a doctor.

He met his wife, Lucy Goddard (without whom this book might never have existed), in Yale Medical School, then chose to become a neurosurgery resident at Stanford, as he was interested in its ‘unforgiving call to perfection.’ That’s quite an elite & punishing path.

For 6 years, he excelled in his residency, tirelessly devoted to his work, perfecting his surgical skills and finally achieving recognition. He was going to be Chief Resident, and it was finally the right time in life to start a family with Lucy. But then he developed unremitting back pain, night sweats and a terrible cough – it was metastatic lung cancer.

There were 2 years between his diagnosis and passing. In the first year, he miraculously juggled cancer treatment and completing the final year of his residency, while supporting Lucy during her pregnancy (they decided to have a child after his diagnosis). In the second year, he ended up having a prolonged hospitalisation and grew too weak to return to work, so he began writing and spent his final months with his infant daughter & loved ones.

when the doctor becomes a patient

As a doctor, reading When Breath Becomes Air was particularly terrifying, because I could see myself in the shoes of any of the people in his story – the doctor-turned-patient, the doctor wife, or any one of the doctors who crossed paths with a fellow colleague who was on a set path to death. I’d much rather not be forced to confront the mortality of myself nor anyone I know & love.

Just as Kalinithi insisted on poring over his own lab results, scans and analysing his treatment options, a part of me wonders if other disease-stricken doctors invariably end up doing the same. As a medical professional, I can imagine it’d be difficult to fully relinquish control, even to another trusted colleague, and play the role of a patient/patient’s loved one.

Perhaps being a patient implies a sense of passivity and implicit trust in your physician to select the optimal treatment out of the full spectrum of options, with the aim of prolonging your life and/or avoiding death. And that goes against every fibre of a doctor’s being, since we’re used to being the ones making decisions and acting like we know best.

In situations like this, sometimes having too much knowledge is a double-edge sword. Having studied too much about the types of cancers & their differing 5-year survival rates, TNM staging and the gnarly side effects of treatments (chemotherapy, immunotherapy, radiotherapy, etc.) is cursed knowledge, and often leaves me feeling terrified that my loved ones or myself will someday be consumed by a disease that I’ve studied, yet am absolutely powerless to defeat.

running out of time

Kalinithi wrote an article titled ‘Before I Go‘, in which he articulated something that so many of us take for granted – the assumption that we’ll live into our old age:

The future tense seemed vacant and, on others’ lips, jarring. I recently celebrated my 15th college reunion; it seemed rude to respond to parting promises from old friends, “We’ll see you at the 25th!” with “Probably not!”

Much like many of our peers, Kalinithi was highly driven, passionate about his chosen specialty, and toiled away in hospital for long hours. He sacrificed weekends, time with his family, instead devoting years of his life to work and possibly procrastinating his happiness.

He assumed that there would always be time afterwards to enjoy the fruits of his labour. That’s certainly a fair and acceptable assumption, since most people live into their 70s/80s, so he statistically should have easily had at least 3-4 decades afterwards to spend time with his family or other pursuits. It’s easy to see cancer as just a statistic, until you’re the one struck with it.

Having someone in my life who strongly reminds me of Kalinithi, working with feverish devotion and being more passionate about work than his own health, I’ve recently developed an irrational fear that illness/death might prematurely whisk him away from me. 😦

We all have expiry dates, but we just don’t know when. Some of us will be taken by accidents, diseases, suicide; some of us will wither away slowly, some will go out in a matter of minutes, and the completely randomness is terrifying.

my favourite When Breath Becomes Air quotes

1. The couple chose to conceive a child after he was diagnosed with the terminal disease, and the book was devoted to their daughter, Cady:

“Will having a newborn distract from the time we have together?” she asked. “Don’t you think saying goodbye to your child will make your death more painful?”

“Wouldn’t it be great if it did?” I said. Lucy and I both felt that life wasn’t about avoiding suffering.”

In a stroke of strange cosmic coincidence, Lucy (Kalanithi’s widow) and John Duberstein (the widower of Nina Riggs, who wrote The Bright Hour as she was dying from breast cancer) fell in love. They were introduced by Nina shortly before she passed, because she thought her husband could use some advice from someone who had also recently lost a partner. :’)

2. Does anything really matter in the end?

Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed.

3. Would you rather know exactly when you’ll die?

The way forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I’d spend time with family. Tell me one year, I’d write a book. Give me ten years, I’d get back to treating diseases. The truth that you live one day at a time didn’t help: What was I supposed to do with that day?

4. 😦

Time for me is now double-edged: every day brings me further from the low of my last relapse but closer to the next recurrence—and, eventually, death. Perhaps later than I think, but certainly sooner than I desire.

There are, I imagine, two responses to that realization. The most obvious might be an impulse to frantic activity: to “live life to its fullest,” to travel, to dine, to achieve a host of neglected ambitions. Part of the cruelty of cancer, though, is not only that it limits your time; it also limits your energy, vastly reducing the amount you can squeeze into a day. It is a tired hare who now races. And even if I had the energy, I prefer a more tortoiselike approach. I plod, I ponder. Some days, I simply persist.

5. This sentence is just so powerful:

Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.

5. The human side of medicine :’)

All of medicine, not just cadaver dissection, trespasses into sacred spheres. Doctors invade the body in every way imaginable. They see people at their most vulnerable, their most scared, their most private. They escort them into the world, and then back out. Seeing the body as matter and mechanism is the flip side to easing the most profound human suffering.

6. The couple’s marriage was suffering due to his work commitments, but they grew close after his illness struck:

We each joked to close friends that the secret to saving a relationship is for one person to become terminally ill. Conversely, we knew that one trick to managing a terminal illness is to be deeply in love — to be vulnerable, kind, generous, grateful.

7. ☀️🌌

To the east, the full light of day beamed toward you; to the west, night reigned with no hint of surrender. No philosopher can explain the sublime better than this, standing between day and night.

8. So we beat on, boats against the current:

Years ago, it had occurred to me that Darwin and Nietzsche agreed on one thing: the defining characteristic of the organism is striving.

9. From the epilogue written by his wife, Dr Lucy Goddard Kalanithi:

This book carries the urgency of racing against time, of having important things to say. Paul confronted death—examined it, wrestled with it, accepted it—as a physician and a patient. He wanted to help people understand death and face their mortality. Dying in one’s fourth decade is unusual now, but dying is not.

10. The book would not have felt complete without Lucy’s epilogue, which was an absolutely heart-wrenching yet beautiful tribute to the man she dearly loved:

The earth is quickly turned over by worms, the processes of nature marching on, reminding me of what Paul saw and what I now carry deep in my bones, too: the inextricability of life and death, and the ability to cope, to find meaning despite this, because of this.

final thoughts

I can’t imagine being 36 and dying of cancer, but it could happen to you, me, or anyone else we know. It’s all too easy to pass asinine comments like “Live each day like it’s your last”, without making any tangible changes to your current life; so, how would your current life priorities change if you, like Kalinithi, were suddenly given just 2 years to live?

I highly recommend reading When Breath Becomes Air, but be prepared to shed plenty of tears – it’s a heart-wrenching memoir that I wish had never been cut short by a cruel twist of fate called cancer. I’d rate it 10/10, because of how sobering a reminder it was to cherish every moment with the people who matter.

Instead of dwelling on thoughts of my indeterminate remaining lifespan, I’ll continue striving towards my dreams, loving foolishly & fearlessly, spending time with my family/friends, exercising more and looking both ways before I cross the road (so I don’t get hit by a bus).

And since we’re on the topic of sad books and sad songs, I was reminded of Ed Sheeran’s Visiting Hours when writing this piece:

I wish that heaven had visiting hours
And I would ask them if I could take you home
But I know what they’d say, that it’s for the best
So I will live life the way you taught me, and make it on my own

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