When Breath Becomes Air

When Breath Becomes Air is a non-fiction autobiographical book written by Paul Kalanithi. It is a memoir about his life and illness, battling stage IV metastatic lung cancer. It was posthumously published by Random House on January 12, 2016.^[1]

In his last year of neurosurgical residency at Stanford University, Dr. Paul Kalanithi experiences negative changes in his health. Rapid weight loss, and severe back and chest pains begin to raise concern for him and his wife, Lucy. Paul worries that a possible cause for his symptoms is spinal cancer – unlikely for people in their thirties. However, when X-ray results in a routine medical check-up return looking just fine, his primary care physician and himself attribute the symptoms to aging and work overload. At thirty-six, Dr. Kalanithi had gained national prominence and become a respected member of the medical community.^[2]

Determined to finish the last months of his residency, he ignores whatever symptoms have not subsided. A few weeks later, the symptoms come back, stronger than before. Around this time, Paul and Lucy experience a rocky moment in their relationship when Lucy feels that Paul is not communicating with her. Visiting friends in New York, Paul is almost certain that he has cancer and says it out loud for the first time to his friend Mike. Returning home, upon landing in San Francisco, Paul receives a call from his doctor telling him that his lungs “look blurry.” When he arrives home with Lucy, both of them know what is happening. The next day, Paul checks in to the hospital and the room where he examined his patients, delivering good and bad news, becomes his own. With this event, the future that Paul had worked so hard for these past years vanishes before his eyes.^[2]

Background

Before writing When Breath Becomes Air, Paul Kalanithi was in residency in neurological surgery and a postdoctoral fellowship in neuroscience. In May 2013, Kalanithi was diagnosed with stage-4 non-small-cell EGFR-positive lung cancer.^[3]

As Kalanithi underwent cancer treatment, he shared his reflections on illness and medicine, authoring essays in The New York Times, The Paris Review and Stanford Medicine, and participating in interviews for media outlets and public forums. He also began work on an autobiographical book of his experiences as a doctor and a patient facing a terminal illness.^[3]

Kalanithi died in March 2015 at the age of 37. His memoir was published posthumously 10 months later.^[4] The book included a foreword by Dr. Abraham Verghese and an epilogue by Kalanithi's widow, Lucy.

Plot

Following the prospect of a better life, Paul’s father moves the family from Bronxville, New York to Kingman, Arizona when Paul is ten. A doctor himself, Paul’s father dedicates most of his time to medicine and is notably absent from the house. Believing that to be a doctor, he would have to be away from the family like his father, Paul becomes disenchanted with medicine. Although Paul and his two brothers enjoy the newfound liberty of their desert town, their mother constantly worries for their academic future in a town that the U.S. census has declared “the least educated district in America.”^[2] Unwilling to let anything halt their learning, she acquires college reading lists and instills in her sons a love for literature. The summer before heading to Stanford University for school, Paul reads Satan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S., by Jeremy Leven. The book’s idea that the mind is the result of the brain doing its work awakes a curiosity in Paul for neuroscience.

After completing degrees in English literature and human biology, Paul feels there is still much to learn. He is accepted to a master’s program in English literature at Stanford, and one afternoon—pushed by his desire to understand the meaning of life— discovers the calling to practice medicine for the first time. Preparing to apply to medical school, Paul uses the time off to study the history and philosophy of science and medicine at Cambridge. He later starts medical school at Yale. During his time at Yale, Paul meets his wife, Lucy, and sees the patient-doctor relationship as an example of life, death, and morality coming together. After two years of classroom learning, Paul experiences his first birth and death in his ob-gyn clinical rotation, when a set of twins could not be carried to term. It is then that Paul understands that intelligence is not enough in the practice of medicine, and that morality is also needed. After medical school, Lucy starts internal medicine residency at UCSF and Paul neurosurgical residency at Stanford. Hard at first, Paul grows used to the rigor of neurosurgery and, in his fourth year, joins the neuroscience lab of a professor affectionately called “V.” In the sixth year of residency, Paul returns to his hospital duties and having reached professional recognition, he feels he has finally found his place in the world.^[2]

Paul’s life takes an unexpected turn when, after weeks of health problems, it is confirmed that he has lung cancer. Images obtained from a CT scan show organ systems compromised by the cancer, causing Paul and Lucy great sadness. Searching for the best experts in the field of oncology, Paul begins treatment with a doctor named Emma Hayward. Because of his status, rather than stepping back and letting Dr. Hayward offer her professional opinion, Paul expects to be treated as a consultant, even if it is his own case. Dr. Hayward suggests to find the root of his cancer before determining treatment options. In the meantime, Paul’s family helps him through his transition from doctor to patient, and together with Lucy, he decides to explore reproductive options before he dies. They visit a sperm bank and make the decision to have a child. Test results arrive and Paul discovers that his cancer is derived from a mutation in the epidermal growth factor receptor (EGFR). This fact gives him a bit of relief because it means that he can be treated with Tarceva rather than chemotherapy.^[2]

Symptoms subside with the treatment and, in Dr. Hayward’s office, Paul feels like himself again. After weeks of using the medication, CT scans show a reduced number of tumors in Paul’s lungs and he becomes determined to return to the operating room. Back in the OR, Paul cannot finish his first surgery because of his health. However, his strength and technique improve over time. With both graduation and a baby due in June, Paul takes another CT scan after months since the last. He discovers a big tumor in his right lung and without getting scared, Lucy and Paul research what other options are available. Paul retires from surgery indefinitely and begins chemotherapy. Paul’s response to chemotherapy is adverse and his health worsens, forcing him to skip graduation. With the failure of chemotherapy, other treatment options do not provide much hope to Paul. His condition becomes so severe that even Dr. Hayward gives an approximation of how much time he has left – something she had strongly refused to do before. On July 4, 2014, Elizabeth Acadia “Cady” is born and Paul is filled with joy, even in his darkest hour.^[2]

Reception

When Breath Becomes Air is a New York Times bestseller, spending 68 weeks on the non-fiction bestseller list.^[5]

Matt McCarthy of USA Today gave it 4 out of 4 stars and said, "It's a story so remarkable, so stunning, and so affecting that I had to take dozens of breaks just to compose myself enough to get through it."^[6] Nick Romeo of The Boston Globe wrote that it, "possesses the gravity and wisdom of an ancient Greek tragedy."^[7] Melissa Maerz of Entertainment Weekly stated that the book was "so original—and so devastating. . . . Its only fault is that the book, like his life, ends much too early."^[8]

Other editions

The first US English edition was released in January 2016 followed by the UK English hardback edition by Bodley Head in February 2016. A UK paperback edition was released on January 5, 2017. The book has been translated and published in 39 languages.

References