When Breath Becomes Air recounts the life of Dr. Paul Kalanithi, a neurosurgeon diagnosed with lung cancer during his last year of residency. With elegant and beautiful prose befitting a novelist more than a doctor, Paul guides readers through his life before and after his diagnosis, a life marked by a search for understanding life, death, and meaning.
As a young man, Paul never considered becoming a doctor, a profession many in his family had chosen. Thanks to his mother’s determination to see her three sons surpass the boundaries that a rural education in Kingman, Arizona could provide, she instilled in them a love of books. Paul quickly became enraptured by literature and decided to follow that love through his undergraduate and graduate studies at Stanford University.
Along the way, Paul also became fascinated with the brain. He wanted to understand how this organism was involved in creating meaning in life. Therefore, coinciding with his literature studies, he also studied biology. These two passions would guide the rest of his life. Through literature, he wanted to find language that gave depth to human experiences. Through science, he wanted to find the boundary separating life from death and what constituted each. When words became insufficient, he decided to enroll in medical school to become a neurosurgeon.
Throughout the book, Paul takes us on...
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This summary of When Breath Becomes Air is written in a way that allows you to share in the experience provided by the memoir. Most of the beauty in this book comes from the relationship formed with Paul as you walk in his shoes. His personal stories and observations are strengthened by his thoughtful voice and elegant prose.
As a neurosurgical resident about to graduate and move into the role of doctor, I knew what the signs of cancer were. When I looked at the CT scan, at the lungs, the spinal cord, and the liver, the diagnosis became clear. I’d looked at similar scans over the years of my training, but those scans always belonged to others. They weren’t like this scan, which belonged to me.
My wife, Lucy, a doctor of internal medicine, and I had noticed the signs during the past 12 months, but neither of us vocalized our suspicions. I didn’t want to admit what the amount of weight I’d been losing or the immense back pain I had started experiencing added up to.
I’d had X-rays done because MRIs for the back were costly, and the results were normal. I knew that X-rays for cancer were more or less futile, but I still took the results and ran with them. Afterall, cancer at thirty-six was not common, especially cancer in the spine. I assumed it was a different type of spinal disorder because even if the odds of cancer were better, they still weren’t as good as other disorders. My training had taught me enough to know that. I accepted the explanation of aging and fatigue and went back to work.
I didn’t want to be a doctor. I didn’t know what I wanted to be. Maybe a writer, but the time when I’d have to decide on a career was far off. I was getting ready to leave for college in less than a month, and the only thing I was concerned about was how much I couldn’t wait to leave my small community in Arizona and enter the shiny world beyond it.
Plus, so many people in my family were doctors, including my uncle and father. From what I knew about it, medicine seemed to equate to long hours and time away from your family.
My father had moved my two brothers, my mother, and me from Bronxville, New York, a picturesque community north of the city, to Kingman, Arizona several years earlier. Kingman wasn’t on anyone’s radar except for as a place to pass through. The desert town was walled in by two mountain ranges. My father had loved the weather, the more reasonable prices, and the opportunity to build his own medical practice.
How he’d convinced my mother to move there was a mystery. A Hindu from southern India, she was deathly afraid of snakes, which were prevalent in the Arizona desert, among other creatures. My friends and I ran freely, roaming the expansive land in...
While my friends headed east to become artists, I was still pondering the intersectionality of biology with literature, morality, and philosophy. I wasn’t sure what the future held for me. Then, one day, I had a sort of divine epiphany---only by being a doctor could I come to learn the answers to my questions. As Whitman had stated, the physician is the only one who can truly discover the physiological-spiritual man. Despite my misgivings as a young man, I was going to become a doctor.
This choice wasn’t an easy one to make. It would require another year of school to get the proper credits just to apply, as well as an 18-month application process. I would also have to turn away from literature. But in doing so, I could start to seek answers from a relationship with those facing life and death.
Some professors felt that leaving academia was a hasty decision. They suggested I use the time I had to study the history and philosophy of science. I was accepted into a program at Cambridge University and headed off to England.
During the program, I became more convinced that to be able to gauge the moral aspects of life and death, I had to address it firsthand. Words were no longer...
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The fourth year of medical school brought decisions about specialties. Many of my classmates were selecting less-intense specialties, those with better hours, more money, and less stress. In those specialities, the responsibility for life was low.
I opted to choose neurosurgery, one of the most demanding specialties there is. My decision was motivated by an experience I had witnessing a pediatric neurosurgeon discussing a child’s tumor with his parents. I listened as he transitioned from physician, detailing the medical implications, to companion, respecting the personal, moral implications and guiding them through their fears.
I saw how the parents, distraught and frightened, were able to find emotional stability and fortitude for the journey that lay ahead. I realized that life, death, and meaning were issues grappled with more often than not within the context of medicine, but beyond that, there were existential factors at play. The body is an organism that will eventually succumb to physical laws, but the meaning encompassed in that body takes on its own trajectory.
Thus, neurosurgeons treat not only the brain, but also the spirit of the person. Every procedure affects...
Part of the neurosurgical residency training is taking time to train in another field. The standard of excellence is high in neurosurgery; thus, the expectation is for you to be well-rounded and excellent in all aspects of medicine to fully excel.
I chose to move into one of the most difficult, yet highly regarded roles: that of neurosurgeon-neuroscientist.
I moved to a laboratory at Stanford to work with scientists focused on the development of neural prosthetics. These devices could allow those without motor functions to control things in the outside world with their minds. The brain sends signals out to sensors that activate the command. What I wanted to do was the opposite. I wanted to manipulate the signals within the brain, a process called neuromodulation.
The possible benefits of neuromodulation were vast. Successful manipulation of neural activity could help treat a number of conditions of the brain and mind, such as OCD, depression, or Huntington’s disease. I set to work learning and experimenting with cutting-edge research. However, a year in, V, the head of the lab, told me he had pancreatic cancer. After he told me, he asked me if I thought he’d made the right...
I’d spent so much of my training learning to account for patients’ identities in my surgical decisions. Yet, in that familiar hospital room, now as a patient, with Lucy next to me, I could feel my identity, that of physician, slipping away. She and I both knew what my scans showed. Cancer lived inside me, had found a number of cozy corners to nestle into. The life I’d been working toward, the role I was going to play in the world, was disappearing.
I’d counseled a number of patients, guided them through the dark so they could see their new futures. But in that instance, I was no longer the guide. I was aimless, lost and unable to find a new path or even see what that new path should look like. My lung cancer diagnosis didn’t sharpen my view on life. It blinded me to life.
Death, which I had turned from a foe into a sometimes necessary associate, no longer waited at my side with deference. Death now sat across from me, and I didn’t know how to address it anymore. I didn’t know how to find the words with which to negotiate. It was as if I was being introduced to death for the first time, and the code of conduct was still unknown.
Lucy and I met with the doctor who would see...
All those times I’d referred patients to physical therapy, I never understood what I was sending them to. Just as you can imagine what losing a parent or child feels like but never understand it until it happens to you, doctors have no real gauge of what the sick go through until we are one of them. Physical therapy was hard, exhausting, and defeating.
I was physically diminished, and at first, just lifting my legs was a struggle. My physical therapist asked what I wanted to accomplish with therapy, and I said the ability to bike and run again, two things I’d regularly and readily enjoyed. Losing those abilities compounded my loss of identity. But each day that I made a tiny step in the direction of progress, I was seeing a possible path back to some semblance of the old me.
After a couple of months, I could sit for thirty-minute intervals more easily. After more time, I was able to socialize with friends again. The first time I got back on my bike, I went six miles. They weren’t the most graceful miles I’d ever ridden and barely accounted for a quarter of the distance I used to cover. But just being on the bike again was a victory.
Still, I didn’t know who I was out in the...
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With my diagnosis nine months behind me, I attempted to recreate the trajectory of my pre-cancer life. I was weary and beaten down physically, but it was all worth it. In a just a couple of months, graduation would be upon me and life would settle into a manageable pace.
There was a job at a university in Wisconsin that encompassed everything I’d hoped for in a post-residency position. The pay was high. There was significant funding for a neuroscience lab. I would be in charge of my clinical service. There was time available, if needed, to address my illness. The position included a professorship with possible tenure. The town was quaint and beautiful. Lucy had a number of career opportunities to choose from. My dreams could be realized with this job.
I knew that without Emma, I could never have gotten back to this place. After my diagnosis, I couldn’t see a way back to who I was before, but she had kept my identity alive despite my misgivings. She had met me where I was and nurtured her moral obligation to lead me forward until I could see the path back to myself again.
Yet, despite the fantasy, I suddenly realized it wasn’t possible to ever be me again…not completely. I...
Time has lost its meaning and luster for me. Each moment moves me farther away from the last relapse. But that same moment is another step toward another one or the final one. Death may still be far off, but I am certain it is not as far off as I would like. With this knowledge, it would be easy to try to cram as much “living” as I can into the time I have left. But cancer is a fickle companion. It doesn’t necessarily take away your time as fast as you think it will, but it makes your body too weak to enjoy it the way you’d like.
There is little to differentiate the days now. If time was arbitrary when I was operating, now it was...
The final pages of When Breath Becomes Air are written by Paul’s wife, Lucy. She describes how Paul died on March 9, 2015, in the hospital with his loved ones by his side. Cady was eight months old.
Paul’s treatment stopped working a few months earlier, at Christmas. He became weaker but kept living as best as he could. They had friends over for dinner, played with Cady, and continued to enjoy each other’s love and companionship. Paul also worked on this book. During his last months, finishing the book was of the utmost importance to him.
The transition to spring brought a resurgence of life in the natural world while Paul’s life continued to wane. In February, he was put on oxygen to help his breathing. More scans were done, showing the growing grip of the cancer in his lungs and the spreading of it to his brain. The new brain tumors brought a shortened life expectancy and would eventually lead to neurological deficits.
The ensuing deterioration of his mind was particularly crushing for Paul, fearing the loss of meaning and independence. Thwarting these devastating effects became the main goal of whatever treatment he would receive.
Lucy remained strong for Paul, but...
Take a moment to reflect on this story.
What is one thing you learned from Paul’s journey? How does this knowledge change how you approach your life?