A Surgeon’s Inspiring Journey to Death

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Every so often, a memoir comes along in which the story speaks to universal themes. For that magic to occur, the author must step aside at times and let others tell their story, too. Moreover, the writing must be clear, vibrant, and above all else honest to the core. The recently published memoir by Paul Kalanithi, MD, When Breath Becomes Air, is one of a handful of recent books that captures universal themes in beautifully rendered prose.

Dr. Kalanithi opens his book with this riveting paragraph: “I flipped through the CT scan images, the diagnosis obvious: The lungs were matted with innumerable tumors, the spine deformed, a full lobe obliterated. Cancer, widely disseminated. I was a neurosurgical resident entering my final year of training. Over the past 6 years, I’d examined scores of such scans on the off chance that some procedure might benefit the patient. But this scan was different: It was my own.”

A Personal Story

At the age of 36, Dr. Kalanithi was on the verge of completing a decade’s worth of training as a neurosurgeon. His journey from medical student to professor of neurosurgery was almost complete after 10 years of relentless training, and, despite newly arising back pain, he was determined to maintain the grueling 14-hour-per-day pace for the next 15 months until his residency ended. He had earned the respect of his seniors, won prestigious national awards, and was fielding multiple job offers from the nation’s top universities. He was also deeply involved with a young woman named Lucy; marriage and children were being planned.

Then it began: The back pain increased; there was demonstrable weight loss and bouts of severe chest pain. Being a doctor, his body was telling him that something was wrong. Reluctantly, he saw his primary care physician. She assured him that it was probably a bout of sciatica, nothing to be worried about. She ordered an x-ray. Dr. Kalanithi tried to keep worst-case scenarios from invading his mind. He was a super-busy neurosurgeon with a bright future, who, in his own words, “had reached the mountaintop…. I could see a catamaran that Lucy, our hypothetical children, and I would take out on weekend sails…. I could see myself finally becoming the husband I’d promised to be.”

Listen to Paul. In the silences between his words, listen to what you have to say back. Therein lies his message.
— Abraham Verghese, MD

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On a trip from his home in San Francisco to upstate New York to visit a dozen college buddies, he experienced a rapid onset of excruciating pain and fatigue. He cut his trip short and returned to San Francisco, and as he stepped off the plane, his phone rang. It was his primary care doctor informing him that the x-rays looked blurry, “as if the camera aperture had been left open too long.” The doctor said she wasn’t sure what it meant. Dr. Kalanithi was. A few days later, his worse fears became reality. At 36 years of age, with a dreamscape life ahead, he was diagnosed with stage IV lung cancer.

Must-Read Prologue

Remarkably, all of this drama, and more, is in the book’s must-read prologue. It’s not a spoiler, as the reader will certainly know that they are reading an acclaimed book by a man who died 2 months before it was published. That in and of itself offers a heightened sense of drama. The celebrated author Anthony Burgess was diagnosed with an inoperable brain tumor when he was Dr. Kalanithi’s age and given a year to live. During that “last year,” Mr. Burgess wrote five novels. Of course, it was a misdiagnosis, and he lived and wrote for a good many years.

Dr. Kalanithi, faced with a deadly diagnosis, also chose to spend his remaining days writing—early on in college, he had toyed with the idea of a career in literature—and the result is a heartbreaking and ultimately beautiful piece of literature, showing, without ever trying too, how much the dying have to teach us about life.

Dr. Kalanithi begins his tale with a stirring account of an adventurous childhood in the desert of Arizona. Right from the start, the reader feels the author’s free-spirited love of life. To his credit, he gives just enough expository work to personalize the unfolding drama of his cancer diagnosis. This culminates with his decision to pursue a medical career while his best friends were flocking to New York to pursue life in the arts. “Walking across campus after a football game, I let my mind wander…suddenly it all seemed obvious. Although—or perhaps because—of my father, my uncle, my elder brothers, medicine had never occurred to me as a serious possibility. But hadn’t Whitman himself written that only a physician could truly understand ‘the physiological-spiritual man?’”

Setting a High Standard for Writing

With a storyteller’s knack for pace and pithy dialogue, Dr. Kalanithi describes his surgical internship in a series of well-drawn case studies, which seamlessly bring the reader into the day-to-day rigors and emotional stressors of a busy hospital. He also knows how to deliver arresting openings. He wrote, “The first birth I witnessed was also the first death.” How could any reader not want more?

Twin girls delivered via emergency cesarean section survived the birth but later died in the neonatal intensive care unit. Dr. Kalanithi handles this human tragedy with finely crafted prose that captures the heart-rattling drama of doctors desperately using all their skills and energy to save two innocents; both die after heroic efforts. This and other stories in this section are so good that they set a high standard for science-memoir writing that will be difficult for others to achieve.

The Silences Between His Words

Part II of this two-part book is titled “Cease not Till Death.” It is aptly titled, as the readers will see. Dr. Kalanithi opens part II with this heartbreaking scene. “Lying next to Lucy in the hospital bed. Both of us crying, the CT scan images still glowing on the computer screen, that identity as a physician—my identity—no longer mattered…. Lucy told me she loved me. I don’t want to die, I said.”

There are many books that cover a cancer diagnosis, bad news about prognosis, a long defiant struggle, employing every therapy in our armamentarium, and a long lonely journey toward death. But this book is special, and its specialness is best described in the foreword by Abraham Verghese, MD. “Listen to Paul. In the silences between his words, listen to what you have to say back. Therein lies his message. I got it. I hope you experience it, too. Let me not stand between you and Paul.”

This book is highly recommended for readers of The ASCO Post. ■