I do not think that there can ever be enough books about anything and I say that knowing that some of them are going to be about Pilates.The more knowledge the better seems like a solid rule of thumb, even though I have watched enough science fiction films to accept that humanity’s unchecked pursuit of learning will end with robots taking over the world.-Sarah Vowell

Monday, May 2, 2016

When Breath Becomes Air by Paul Kalanithi

If you have not already heard of Paul Kalanithi, he wrote in early 2014 an op-ed piece for the New York Times called "How Long Have I Got Left?", which caused a bit of a stir. It is not often you read something so magnificently and beautifully written by a neurosurgical resident who is dying from cancer at the age of thirty-six-years-old. But Paul is not a typical anything, really. Here is his vitae: Graduated from Stanford University with a BA and MA in English literature and a BA in human biology. He earned an MPhil in history and philosophy of science and medicine from the University of Cambridge and graduated cum laude from the Yale School of Medicine, where he was inducted into the Alpha Omega Alpha national medical honor society. Her returned to Stanford to complete his residency training in neurological surgery and a postdoctoral fellowship in neuroscience, during which he received the American Academy of Neurological Surgery's highest award for research.  Impressive, huh? His journey is an unusual one, but a very fascinating one. And, yes, going in you know that he did not live long enough to finish it, but that does not matter.

The first page you read will tell you in great detail that every name has been changed to protect the privacy of the patients. And when they say every name, they include names of other doctors he worked with and friends. They go to great lengths to completely obscure things, and not just because they have a legal obligation, but because they have a moral one. In this day and age, there is always some idiot out there who will give it a try to figure out who these people are for whatever reason. I'm rather confident that they will not be able to.

He opens with a prologue that takes you through the time he was discovering that something might be wrong. A residency is a very difficult time. As they say, "The hours are long, but at least the years are short." A neurosurgical residency is another kettle of fish. His marriage was starting to show strain. His wife Lucy, a doctor in internal medicine, knew that he was keeping things from him and they were barely seeing each other. His back was aching and he was losing weight, but an X-ray, something he knew wouldn't show what he suspected it might be, no matter how ridiculous, was clear. And then he started gaining weight and his back eased up. The massive fight came about when she found out that he appeared to still be worried about it and wasn't talking to her. The symptoms came back with a vengeance and he went to his PCP to have a chest X-ray, which showed that he had lung cancer. [I do feel the need to insert here that he was not a smoker, or around second hand smoke. It's cancer. We do not understand everything about it. Sometimes people just get it.] The two of them were already in the process of trying to find a way to mend fences when the diagnosis came in and there was no question then of what really mattered most to them.

But that is not where he started out. His father, a doctor (as is his uncle), moved the family from Bronxville, New York to Kingman, Arizona because the cost of living was less and he was hoping to be able to send his sons (Suman, Paul, and Jeevan) to the best colleges and to establish a regional cardiology practice of his own. His mother is Indian and Hindu, while his father is Christian, which meant the marriage was condemned on both sides and a great many familial rifts. It also meant that his mother was forced to face her extreme fear of snakes. Paul's older brother, Suman, went off to Stanford when they moved, after graduating from an elite prep school back in New York. At that time, it turns out, the U.S. Census had identified Kingman "as the least educated district in America." [I really would have expected that to have been in Mississippi or North Carolina as the two states seem to be in a battle over the decades over being last in education. But this is one school district, not all of them in one state.] His mother was horrified. She would cry at night, worried that her children would not be able to get into college.

This did not, however, last for long. His mother is a force of nature. I don't think Kingman knew what hit it. She had been trained in India to be a physiologist, she married at age twenty-three and became a mother and raised three boys instead. Now she was going to educate them herself. She got a hold of a "college prep reading list" and began handing them to Paul. He was ten when she handed him his first book, 1984 by George Orwell. His reading list over his lifetime is amazing and puts me to shame. When he was twelve he was picking them out for himself and his brother Suman was sending him books he had finished reading in college. His mother joined the school board, "rallied teachers, and demanded that AP classes be added to  the curriculum. She was a phenom: she took it upon herself to transform the Kingman school system, and she did."

When he went off to Stanford he "was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful? I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain."  He would spend a great deal of time reading and studying trying to figure out human nature and life, until one fateful summer when a choice is presented: an opportunity of a lifetime to study rare birds or be a chef at a summer camp in the Sierra Nevada Mountains actually living life.  Yeah, his biology advisor nearly had an apoplectic fit.

But pursing an MA in English literature did not provide the answers he sought either. Even though his father, uncle, and now his brother Suman (who became a neurologist) were doctors, it never occurred to him to be one. But now he was thinking that the answers he wanted he would likely have to find in medicine. He had to wait about eighteen months to get into med school, so he used the time to take the classes he needed and to get that MPhil over in Cambridge. He met his wife, Lucy, at medical school. He chose neurosurgery because it "seemed to present the most challenging and direct confrontation with meaning, identity, and death." They married after med school and headed to California for their residencies: him at Stanford, her at UCSF Medical School.

"My first day in the hospital, the chief resident said to me, "Neurosurgery residents aren't just the best surgeons--we're the best doctors in the hospital. That's your goal. Make us proud." The chairman, passing through the ward: "Always eat with your left hand. You've got to  learn to be ambidextrous." One of the senior residents: "Just a heads-up--the chief is going through a divorce, so he's really throwing himself into his work right now. Don't make small talk with him." The outgoing intern who was supposed to orient me but instead just handed me a list of forty-three patients:"The only thing I have to tell you is: they can always hurt you more, but they can't stop the clock." And then he walked away."

Now, here is where neurosurgery residency is different. About midway through, you have to go away for additional training in some other field. An example he uses is neurosurgeon-journalist Sanjay Gupta. But mostly, the doctor will choose something a little closer to the pasture. He, of course, chose neurosurgeon-neuroscientist (one of the hardest) and spent about a year or two working in a lab that develops neural prosthetic technology that, for example, helps a paralyzed person mentally control a computer or a robot arm. Paul wanted to write signals into the brain, or neuromodulation. This would, for those using a robot arm, be able to feel how hard they are holding something, before they break it. But much more importantly, if you can control neural firing in the brain, which is what this this would be doing in a much broader sense, this would lead to innumerable treatments of currently "untreatable or intractable neurological and psychiatric diseases, from major depression to Huntington's to schizophrenia to Tourette's to OCD." This would not just be ground breaking science, it would be a miracle for those who have these diseases. Which leaves me struggling a bit with the fact that his God (who is my God as well) would take him from this earth at thirty-six. He was extremely intelligent and once he finished with this lab, it would be something that he continued working on his whole life. There would have been a very good chance that he could have found the answer, or if not, at least moved science way down the road and made great advancements that so many could built upon in ways I cannot even begin to imagine. But that was not to be his fate.

There are many stories from his time of residency. Don't worry, the man's feet are indeed made of clay. He goes in with lofty ideas. What doctor doesn't? But he finds himself becoming immune to the human condition and being the doctor I'm sure we've all come up against at some point or another. What does make him an extraordinary man is that he realizes this and vows to do better and does. But he is still human. His diagnosis  came when he was just finishing up his residency and being assured of the position at Stanford of professor of neurosurgery-neuroscientist (as well as at many other places). He and Lucy were at the point of wanting to have children. Now it became a question of should they, as he had no idea if he would be around for a month or the next ten years or what. Was it fair to her to burden her with that? Does he try to go back to being a neurosurgeon? What is it that he really wants out of life? He had spent so much time reading up on life and death and trying to figure it out, but it's not until you are staring it in the face, that you truly understand it.

Note: This, to yours and my great surprise, is not an overly sad book. It is quite a reflective book on a life lived and a look at death. He died before he could finish this, but if feels finished. But that is why one has editors, after all. His wife writes a lovely epilogue that fills in the blanks at the end and really explains who he was to her, a different man than what you find in the book. And that he was laid to rest in a willow casket in a field overlooking the Pacific and that just makes me feel so much better. I really do like willows and the Pacific is so beautiful.
Note: For further reading on cancer, I suggest, though have not yet read, The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee. Also, Ken Burns amazing (but what has he done that wasn't amazing?) three part, six hour documentary The Emperor of All Maladies, which I have seen and highly recommend.

Link to Amazon: http://www.amazon.com/When-Breath-Becomes-Paul-Kalanithi/dp/081298840X/ref=sr_1_1?s=books&ie=UTF8&qid=1462210151&sr=1-1&keywords=when+breath

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