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When Breath Becomes Air: A Reflection
I didn’t know Paul Kalanithi, but I knew of him; we shared patients. It was in January of my final year of fellowship, sitting in Tressider Union, when I received a link to his New York Times article from a colleague. Alone I sat, reading his reflection on being diagnosed with a terminal lung cancer.
His memoir, When Breath Becomes Air, was recently given to me by a dear friend. I sat down and read its entirety one afternoon; I read it perched on my favourite pier jutting into the Hudson River. Paul’s writing is warm and its cadence invites you into the story of his life, education and training. His story resonated with mine, partly because of our shared profession and certainly because we shared a place of training, but mostly because of his love of literature and his determined inquisition into the meaning of life and our relationship with death.
“Books became my closest confidants, finely ground lenses providing new views of the world … ” he writes. “I was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful?” I was particularly struck with his references to Tolstoy. As I entered my undergraduate studies, I plodded through biochemistry and organic chemistry only to revel in my time with Tolstoy’s magnificent stories and his own fascination with mortality. Indeed, on the day prior to my first day of my intern year, I sat in Union Square and re-read The Death of Ivan Ilytch, trying desperately to understand what lay before me as a physician.
Paul ultimately decides to pursue medicine because he realizes that the raw material for meaning is the “relational aspect of humans.” I am particularly fond of his description here: “I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion.” Thus, like everything in the cosmos – movement, space, velocity, perception, etc. – meaning is also relativistic. We can only gauge the depth our own stories with respect to the experiences we have accrued. The sources of these experiences are varied, but direct relationship – ‘in communion’ with others – he argues, is the most prominent. In other words, it is our connection with others that is the medium from which we sculpt our identity, our mission, and our meaning. He therefore decides: “It was only in practicing medicine that I could pursue a serious biological philosophy.”
Divorcing Thoughts from Feelings
His recollection of human anatomy at the outset of medical school is perfect. “Cadaver dissection epitomizes, for many, the transformation of the somber, respectful student into the callous, arrogant doctor.” I was brought back to my first week as a medical student when I dissected open a cadaver’s thorax and intimately probed his heart and lungs. For me, this certainly began the glorification of cognition, abstractions and jargon above that of feeling and emotion. A callous is a protective mechanism and cutting open a deceased human is, I believe, when many medical students begin to dissect away their scientific and professional lives from their affective ones; when we, as physicians, learn to protect ourselves with a cloak of rationality. When reflecting on experience, we do so through two lenses: thoughts and feelings. What we tacitly learn in medical school and then residency is to slowly close one eye. In our conferences, we focus through the lens of physiology and chemistry and pharmacology – our abstract, cognitive world thrives – but as we do so, our perception of depth and weight of the situation is lost – our affective world withers. As a poignant reminder, Paul recalls studying ECGs as a medical student, learning about malignant and fatal arrhythmias, when his future wife, Lucy, breaks down into tears realizing that the cardiogram from which they were learning represented the end of someone’s life.
And this took me back to one of the most distressing cases of my training. A very young woman died; I ran her resuscitation. We worked for an hour trying to get her back, but we didn’t. Afterwards, I printed off her telemetry strip – the last 5 minutes of her cardiac activity, and I keep it with me. With each move of my apartment, I inevitably unearth it, at the bottom of a box; I stare at it with two eyes wide open. With one eye, I see her heart rate and rhythm degenerate, I see her abnormal pulmonary vasculature, her inability to exchange gas, and I see the moment that I began CPR on her. With the other eye, I see her husband collapse in the corner in horror. I see her two confused children with the rest of her family that night begging me for answers. I see the sleepless nights I suffered for months thereafter. The weight of that moment, and countless others – as Paul also recollects in his training – carry “… weight, and things that have weight, have gravity.”
Responsibility and Adaptation
And what is the result of repeatedly encountering such situations – an inevitability of our profession? Paul relates a story from Nuland’s How We Die, of the young Nuland unable to deal with the gravity of a dead patient, taking it upon himself as a medical student to open the patient’s chest and attempt manual cardiac massage, unthinkable today, but still in “… the heroic spirit of responsibility amid blood and failure.” Throughout his training, Paul relates a profound sense of moral responsibility for his patients – grappling with the inherent tension generated as a fallible creature persistently striving for infallibility. And in response to this tension, like many residents, he learns how to adapt. “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.”
While closing an eye to the weighty emotions of our training can protect us from drowning, it may also blind us to our amazing moments; I recalled some from my residency. The man dying of biliary sepsis at 3 am – too sick for the operating room – for whom I successfully petitioned to have the interventional radiology suite opened, against the wishes of many sleep-deprived physicians, nurses and technicians. The pulseless and ashen man whom I helped resuscitate and detected a large myocardial infarction on his ECG – only to perform CPR on him again as we wheeled him into the cardiac catheterization lab. Weeks later, I shook his hand and received a group hug from his family. And then there was my father who, while I was jetting about the continent on residency interviews, ruptured an abdominal aortic aneurysm while at home. A team of dedicated vascular surgeons saved his life; he spent a couple of weeks in the ICU, but 6 months later, he was able to watch me graduate from medical school. The graduation ring that he gave me, I wear as a reminder to pay forward the gift I received. A reminder to prevent me from reflecting on my professional experiences through only the lens of science.
As Kierkegaard noted, “life can only be understood backwards, but must be lived forwards.” Meaning is sculpted from a bedrock of human relationship, fashioned by contemplation and emotion and then set by reflection. Paul writes “… surely intelligence wasn’t enough; moral clarity was needed as well. Somehow, I had to believe, I would gain not only knowledge, but wisdom too.” He goes on “… it had occurred to me that Darwin and Nietzche agreed on one thing: the defining characteristic of the organism is striving.” The implication, I believe, is that while our relationships form meaning, our connection with strife and sorrow fashions wisdom – a universal lesson observed with pressing clarity by a reflective young man standing up and perceiving the swiftly advancing horizon of his existence. His wisdom becomes clear, poignant, and hardened by his untimely finitude, and made especially sober in relation to his newborn daughter, Cady.
I encourage everyone to find a good spot with When Breath Becomes Air and read it with both eyes open. Take communion with Paul’s words, reflect and allow his wisdom to seep into your person. His story will give you pause and provide a new lens through which you can view your world. When I closed his book, I took a breath and looked up across the glittering Hudson – the words of Aeschylus rose to mind:
“Even in one’s sleep, pain which cannot forget, falls drop by drop, upon the heart, until against our will and in our despair, comes wisdom, by the awful grace of God.”