Paul Kalanithi's When Breath Become Air

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

I anticipated that this would not be easy book to review; after all the author died whilst writing it and the book represents his professional and personal testament. My anxiety was that I might be seen as over critical or even disrespectful but at the same time the reader of this review deserves, as far as is possible, an honest review untarnished by undue sentimentality. Before offering a perspective I think it is important to know that the book is essentially unfinished. Unfinished in the sense that Paul Kalanithi died before he could complete it. As it happens the unfinished nature of the work is one of its strengths. It has a rawness and immediacy, particularly in part 2, that is genuinely compelling. Secondly, if you do decide to read the book (and as you will see I think you should) don’t read the foreward by Abraham Verghese until the end; it is a distraction and actually makes starting the book more difficult. Kalanithi was young when he died from metastatic lung cancer, from my perspective very young. He was just at the cusp of a potentially stellar career as a neurosurgeon (he was completing the very end of his specialist training when diagnosed), though as you will see through a tremendous force of will he completed that training and certified. Kalanithi was an American and some of the Americanisms can and do grate at times, but in general his use of language is refreshing, reflecting his wider scholarship; he was very well read for a doctor! As with a number of my recent reviews the author had an elliptical path to medicine and it is becoming increasingly clear to me that such individuals bring a different (more mature?) perspective to medical training and the practice of medicine. I would argue they are more insightful and to some extent circumvent the hard learning that most of us went through in the earlier phases of training at Medical School and beyond. He has an interesting take on medicine seeing it more as a journey into dying than living – and to be clear I don’t believe this is because he himself was dying when he wrote it. The book is probably worth reading just for that perspective, and his reference to a quote from Sir Thomas Browne’s Religio Medici  (Osler was a fan also); "With what strife and pains we come into the world we know not, but ‘tis commonly no easy matter to get out of it” is especially telling and in the light of the continuing unresolved debate on assisted dying, highly relevant. Part 1 of the book is a re-telling of his time before and at Medical School and his subsequent specialty training. It is this section of the book that is perhaps most hampered by the early death of the author. One gets the sense of a need to recount and record key events before they are lost. They are well done and give an insight into an unusual intellect. The attempts at reflection however hint at something much more profound and give a flavour of what the book might have been – trouble is when you read part 2 you wonder if Kalanithi would have got round to this particular story telling, ever. So what you see now may be the product of those feelings of impending mortality – the book is not the weaker for this. Returning to the theme above from Religio Medici, PK writes (and I think this is a rare insight in a junior trainee) of the dilemma of when to act and when not:

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)