In the last couple years, I have read several books written by physicians. When Breath Becomes Air, by Paul Kalanithi, a neurosurgeon, is the latest one.   My wife recommended the book to me last year and it also made its way to Bill Gates’ heavily-followed reading list recently.   The book may not be as grand as works by other doctors. It is a relatively short read but it packs lots of power and wisdom as Kalanithi took us on the journey of self-discovery, the grueling but rewarding neurosurgeon apprenticeship, and in a twist of faith, becoming a cancer patient right before reaching the peak of his career.

Paul Kalanithi was from a family of physicians and scientists. When Paul was a teenager, his father moved his cardiology practice and family to Arizona from the North East.  In his formative years, Paul was more interested in arts and philosophy than science. Despite his family’s background, he was planning to become a writer as he was interested in understanding how people think. After receiving degrees in literature and philosophy from Stanford and Cambridge, he discovered the key ingredients for a great writer: good material and rich experience. When he realized that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context, he was drawn back to the family’s orbit of medicine. When he was attending Yale School of Medicine, he met another medical student, Lucy, his future wife.  Despite his lack of science background in his earlier college training, he excelled in medical school and decided to focus in neurosurgery after the residency requirement.  The choice appears logical given his interest in people’s thought process. Neurosurgery is widely regarded as one of the most difficult specialties in medicine and it is definitely not a lifestyle choice for medical school graduates.  Neurosurgeon needs to learn everything about the brain, arguably the most important human organ but probably the least understood part of our body, and use sophisticated technology to carry out surgery.  Opening someone’s skull and fixing some issues deep inside the brain not only requires knowledge and technology sophistication, it requires superior dexterity in hand-eye coordination, tremendous stamina and ability to handle pressure.  A small mistake can change the person, literally.  As such, neurosurgery fellowship is long and especially grueling, compared to other medical specialties. Paul was clearly not the average medical school graduate, or the average neurosurgeon fellow.  During his busy neurosurgery fellowship, he found time to collaborate with research labs nearby. After the expected completion of the apprenticeship, in addition to his clinical duties, he was planning to perform scientific research in neuroscience.  He was aiming to become both a skilled clinician and an academic star.

When he nearly reached the pinnacle, he was diagnosed with terminal lung cancer, a rare incident for a young healthy adult without family history of cancer diseases. His initial reaction to the diagnosis was denial but he battled the disease with unbelievable courage and tenacity.  Obviously, he knew a thing or two about the life expectancy of late-stage lung cancer patients. It was a difficult learning and adjustment process for him to reverse role as a patient and reset all expectations. The most difficult part was to live with the uncertainty of the amount of time he was left with (like all of us, albeit much shorter).   It can be six months or it can be more than six years for the lucky patient.  During the first few months, Paul was reacting well with the drug and chemo, raising hope that he could beat the average.  He even went back to perform neurosurgery and endured the long operating hours.  He was also interviewing for a potential faculty position in Wisconsin as the hope of full recovery was promising at one point.  Some may say Paul was crazy to work again so quickly but I think the cancer diagnosis crystalized his thinking about priorities: his wife, his family and his work.  Paul decided on two goals after his cancer diagnosis.  Paul and Lucy wanted to have a baby, and he wanted to write a book to be dedicated for their son or daughter. Before he was diagnosed with cancer, Paul had marital problems with Lucy. Cancer, in an odd way, enabled Lucy and Paul to reconcile. Lucy delivered a baby girl two years after Paul’s diagnosis.  Paul reached both his goals before he passed away at the age of 38 in 2015.

The stereotypical (at least in my mind) physician is conservative and dry.  Paul’s book changed my thinking. Learning the science is obviously hard work but the most important part of medicine is the communication with patients.  I never quite understand the logic of requiring an undergraduate degree before a student can pursue a medical education.  Reading through Paul’s prose, one can clearly see the benefit of a strong liberal arts foundation. How can a physician relate with patients effectively without a good understanding of history, literature, philosophy or human conditions?  In fact, science is arguably the easier part of the equation, especially with the advance of technology.  The harder part is to form judgement based on incomplete information and show empathy to the patients and their family, or in Paul’s words, “guiding a patient or family to an understanding of death or illness.”  Perhaps, the threat of AI taking over medicine is overblown.  Yes, AI may be able to provide same or higher level of diagnosis accuracy in some cases, the job of bridging science and disease implications can only be performed by a skilled physician.

My terse summary above doesn’t do Paul justice as he is a first-rate writer, even in his significantly weakened condition.  It is impossible to describe the difficulty of writing this book. Near the end, Paul was so weak that he could barely eat anything but he kept writing. This is a bitter-sweet story.  As Paul said in the book, he had already outlived two Brontës, Keats, and Stephen Crane.  An ambitious individual, Paul may be disappointed that he didn’t reach the original goal of becoming an academic star and a professional author. I believe Paul did a great service to all of us by sharing his wisdom and experience. We are now accustomed to living longer but we also manage to stuff it with busy but often meaningless activities.  The book is a valuable addition to the genre of autobiography and provides a unique perspective of time, life and death. I highly recommend it to everyone.

Let me end with my favorite phrase by Paul: you can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.  Keep striving.



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