ALiEM Bookclub: When Breath Becomes Air

Dr. Kalanithi was a chief resident in Neurosurgery at Stanford University when he was diagnosed with stage IV lung cancer. “When Breath becomes Air,” is a touching chronicle of his initial journey into medicine and neurosurgery and subsequent transition to the role of patient after his cancer diagnosis. This profoundly moving memoir is a tribute to his young life and family that he had to leave behind, but also a sad glimpse of the potential that this promising young doctor and author never will attain.

Summary

When Breath Becomes Air starts with a moving foreword by Dr. Abraham Verghese [link] (@cuttingforstone), that anticipates the poignancy, brilliance, and beauty that we find in the subsequent pages:

“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. It is a gift. Let me not stand between you and Paul.” – Abraham Verghese

Prologue

The prologue paints a picture of Dr. Kalanithi’s life at the time of his diagnosis: busy, on an upward trajectory to success, and not without some marital tensions. “At age thirty-six, I had reached the mountaintop; I could see the Promised Land… I could see a nice catamaran on that sea that Lucy, our hypothetical children, and I would take out on weekends. I could see the tension in my back unwinding as my work schedule eased and life became more manageable. I could see myself finally becoming the husband I had promised be.” He suspects his cancer diagnosis for quite some time, but his busy life delays his workup. When he finally receives his diagnosis of lung cancer, he writes, “And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.”

Part 1

Part 1 begins with Dr. Kalanithi’s childhood in Kingman, Arizona. We, the reader, then follow his path to college at Stanford University, medical school at Yale University, and end with the recent present- Paul as a highly esteemed neurosurgery chief resident. Through this upward climb in his early training, he gracefully addresses complex themes, including of the meaning of life and death, spiritual transcendence, the “moral mission” of medicine, identity, and the price of being a physician.

Part 2

Part 2 opens with a quote from Michel de Montaigne, “he who should teach men to die would at the same time teach them to live.” This sets the tone for the second half of the book, which focuses on Dr. Kalanithi’s experience of living, working, and making decisions about the finite future when faced with a likely terminal illness. His identity shifts from physician to patient, and the future he had been so diligently planning evaporates. He has to stop working. His oncologist urges him to focus on his values, but at this point, he is no longer sure of his identity. Literature helps with the transformative process of exploring and settling his “new terrain.” At some point, “the seemingly impassable sea of uncertainty” parts, and he wills himself to focus on living instead of waiting to die. In this moment, he decides that he needs to return to the operating room. The rest of the memoir describes various pivotal moments, a few disheartening, but overall, hopeful and uplifting between himself, his doctor, his wife, his coworkers, and most poignantly, with his daughter.

The Other Author

Dr. Kalanithi died before completing his book. The work closes with an epilogue written by his wife, Lucy. She recounts his last few days and the decision to move towards comfort care. Through his last moments, they maintain the love they shared throughout their relationship. She also explains the urgency and determination with which Dr. Kalanithi wrote this book. His goal was to help others understand “what lies up ahead on the road,” and thus to live a more meaningful life.

Analysis

Dr. Kalanithi’s work is particularly powerful because we identify with him as a young physician. It is an honest, open, and human account of his journey. He describes not only the trials of being in a rigorous medical training program, but also family issues such as marital troubles and the desire to have children. All are typical of the life and struggles of a resident physician. We feel kinship, making his subsequent diagnosis of cancer jarring. It reminds us both of our own vulnerability and also of the humanity of our patients by demonstrating how suddenly and unexpectedly we, too, could be in their position.

The book also challenges us to examine the extent to which we delay other aspects of life while in medical training. When we enter rigorous training programs, we trade hard work in the present for the idea of future benefit. The book is a stark reminder that the future is not guaranteed. Dr. Kalanithi’s perspective transitions from examining life’s meaning as an academic question, through literature and neuroscience, to examining the same question with the urgency of someone for whom death is imminent. This transition is meaningful and instructive for the living. Dr. Kalanithi has succeeded in helping us to understand whether for ourselves, our families, or our patients, a little more about “what lies up ahead on the road”.

Application to Clinical and Academic Medicine

We encounter several applications to clinical and academic medicine in When Breath Becomes Air. The first application is to physician wellness. Dr. Kalanithi’s story encourages reflection on our own priorities and work-life balance. Further, it encourages us to reassess our approach to seriously ill and dying patients. Dr. Kalanithi highlights the important role of his oncologist in navigating his post-diagnosis journey. It encourages us all, as physicians, to remember to attend not only to our patients’ medical needs but also to their human needs.

Google Hangout Discussion

Discussion Questions

1. Consider the following quote: “I had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking. Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining of life and death. I had thought that a life spent in the space between the two would grant me not merely a stage for compassionate action but an elevation of my own being: getting as far away from petty materialism, from self-important trivia, getting right there, to the heart of the matter, to truly life-and-death decisions and struggles…surely a kind of transcendence would be found there? But in residency, something else was gradually unfolding. In the midst of this endless barrage of head injuries, I began to suspect that being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun. I was not yet with patients in their pivotal moments, I was merely at those pivotal moments. I observed a lot of suffering; worse, I became inured to it. Drowning, even in blood, one adapts, learns to float, to swim, even to enjoy life, bonding with the nurses, doctors, and others who are clinging to the same raft, caught in the same tide.” (p 81-82). All physicians experience this adaptation to some extent. What can we do to avoid becoming inured or overly adapted, as Dr. Kalanithi describes through the course of our careers?
2. One of the remarkable parts of Dr. Kalanithi’s journey is the brief period when he returns to work as a neurosurgeon during treatment. Would you return to practicing medicine if faced with a similar situation?
3. Does knowing Dr. Kalanithi’s story change your own calculus regarding investment in the future versus living in the here and now?
4. On page 149, Kalanithi writes, “To understand my own direct experiences, I would have to translate them back into language.” What role should the the arts, including writing and literature, have in medical training?
5. Kalanithi speaks of his responsibility to act as “death’s ambassador,” when he can no longer act as “death’s enemy.” How can we better guide patients and their families to an understanding of death or illness, especially if we have not experienced such losses firsthand?
6. It seems extremely difficult to transition from physician to patient, from being in a position of power to one of complete reliance. Dr. Kalanithi has a particularly glaring reminder of this contrast when he is treated crassly by a resident on-call overnight (p. 187). How can we remind ourselves, when we are feeling overburdened by our workload and perhaps emotionally exhausted, to have more empathy for our patients? Have any of you been a patient? What was it like? How could the medical team have made you feel more empowered in your care?

Further Reading

Hafner, Katie. Keeping Dr. Paul Kalanithi’s Voice Alive. 2016. New York Times Health. Jan 22. [link]

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