Paul Kalanithi's When Breath Become Air
19 December 2016
Prof. David Sowden's winter book review - Paul Kalanithi - When Breath Become Air


rushing a patient to OR to save only enough brain that his heart beats……….. condemned to an existence he would never want …. I came to see as a more egregious failure than the patient dying”His reference to a “twilight existence of uncounscious metabolism becomes an unbearable burden” is more poignant in the light of what is to follow. He writes especially well of the risk of desensitisation to death and suffering:
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 nurses, doctors and others who are clinging to the same raft, caught in the same tide.”A paragraph I think all medical students and trainees should confront and reflect on, and some of their seniors also. Additionally, his description of the thoughts that went through his mind when he heard a friend had died after a car accident and subsequent neurosurgery and resuscitation are starkly referenced and offer an insight into how we, as doctors, view illness, disease and the consequences thereof so radically differently from most of the rest of the population. Including, in my experience, many other health professionals. Kalanithi neatly ties this event to the risk of losing empathy and a sense of common humanness with patients and of becoming Tolstoy’s stereotype of a doctor. This needs more of an airing than is currently the case at Medical School and Foundation Programme training, especially. It is perhaps worth us all pondering on his reflection that:
When there is no place for the scalpel, words are the surgeon’s only tool”.I could go on as there is much more to commend in this part of the book but Part 2 where “death, so familiar to me in my work, was now paying a personal visit.” is without doubt the core of this important book. It is worth noting that Kalanithi and his wife (also a doctor) are/ were religious but at very few points does this actually impact on his writing and reflections. And where it does it offers useful insights for those of us who are agnostic and atheist. I really don’t want to say too much about this part of the book as it will detract from your initial reading but suffice it to say that it speaks volumes about how the practice of medicine can and does drive doctors to extraordinary and probably unwise courses of action. It also speaks to what it is to be a patient and the fact that sometimes patients want benign paternalism/maternalism from their doctor, not just a list of options that underpin so called informed consent. If for no other reason it is worth reading this book for the lead up to this truly important statement:
There we were, doctor and patient, in a relationship that sometimes carries a magisterial air and other times, like now was no more, and no less. than two people huddled together, as one faces the abyss. Doctors, it turns out, need hope, too.”Paul’s wife writes an important and moving epilogue that really rounds the book off well. This is far from being a book just for clinicians – it is a book for everyone, but clinicians and doctors especially will have much to cogitate on at the end. When breath becomes air. Paul Kalanithi Bodley Head / Penguin Random House ISBN 978 1847923677 Prof. David Sowden MBChB, FRCGP, FRCOG, FFSEM, FAoME, DCH. Now retired. Formerly : Dean of Post-Graduate Medical Education East Midlands (2000 – 2012) Director of Medical Education England (2008/09 and 2012)