When Breath Becomes Air: book review

Book Review: WHEN BREATH BECOMES AIR by Paul Kalanithi 2016 Penguin/Random Publishing

As a boy growing up in the desert town of Kingman, Arizona, Paul Kalanithi was certain he would never become a doctor like his father or so many others in his family. His father was never home until late at night. Friendly, offering brief encouragement or advice, but hardly ever available. If asked what he wanted to study in college, Paul was vague---maybe writing; maybe something about life's meaning . . . something about the mind . . .

During his senior year in college, his class visited a home for people who had had severe brain injuries. The place was a storehouse, really; a place for those whose families had long ago given up visiting them, a place to exist, but not to live. “Only later would I realize that brains give rise to our ability to form relationships and make life meaningful. Sometimes, they break.”

Some of his classmates graduating from Stanford headed for New York to pursue life in the arts, but that didn't quite seem to fit him. He couldn't let go of the question: Where did biology, morality, literature, and philosophy all come together? The answer came to hm, “Set aside the books and practice medicine.” It would take him a couple of years to make up for the lack of chemistry and physics in his previous studies, but he gained admission to a whole new world at Yale Medical school.

Many books have been written about the medical school experience and the exotic diseases the student may encounter. Kalanithi's visit to 'the home for broken brains' apparently stuck firmly in his mind. He thought he might become a psychiatrist, studying diseases of the mind.

But he saw that the brain was the physical engine that operated the mind, and he resolved to become a neurosurgeon. Speculation on theories of psychiatry gave way to what he called the 'moral mission of medicine' which is fixing what is wrong. “The patient is more important than the paperwork.”

The training period for a brain surgeon is among the most demanding and lengthy that a medical school graduate can undergo---six to eight more years beyond the four years of college plus the four years of medical school. Increasing responsibility of the senior surgical resident requires twelve- to fourteen-hour days on duty, regardless of fatigue. Speed and technique are not the only things that matter. Talking with the patient and family at the right pace; always leaving room for hope, takes time and empathy. It almost destroyed his marriage. He and Lucy met in first-year med school---she entered internal medicine--- and they were very much in love, but she was beginning to feel the strain of his continual duties in the hospital, and suggested marriage counseling.

During the last year of training – chief neurosurgical resident – he experienced chest pain and weight loss. He and Lucy have a rare afternoon taking in the sun at a San Francisco park. Lucy glimpses his phone screen displaying some search results: “frequency of cancers in thirty- to forty-year-olds.” He didn't want to discuss it. She didn't accompany him on a trip a few days later; said she had some things she needed to sort out. He began suffering intolerable, screaming-in-pain back spasms; cut his trip short. Back at home he told her he had cancer. She knew. The distance between them vanished. “I will never leave you,” she promised.

Paul was admitted to the hospital as a patient. His new doctor, Emma Hayward, came into the room to introduce herself to him and his family (most of them doctors too.) He supposed she could tell him about survival statistics.

“No,” she said, “Absolutely not. We can talk about treatment later. And about going back to work, too, if that's what you'd like to do. I'll see you Thursday after the tests I've ordered are back.” His family contacted many of their fellow doctors to find out the best treatment for him. To their surprise they found that most recommended Dr. Hayward as not only world-renowned, but compassionate, knowing when to push and when to hold back.

And with that, the future Paul and Lucy had anticipated for so long evaporated. But his curiosity and intellect remained fully active. Some conditions are universal; one he had always seen and accepted was that death comes to each one of us. What is it that makes my life worth living? he asked. Dr. Hayward laid it out for him: What do you want to accomplish?

There were several things. He had already begun healing his marriage by opening his thoughts to Lucy. They discussed whether to have a child. Whether to return to the practice of surgery, or to take a professorship. Above all, he wanted to write this book, to encourage people to not give up living just because of a diagnosis. “A diagnosis is not the end,” to quote Dr. Hayward, “or even the beginning of the end. It is just the end of the beginning.”