Book Review When Breath Becomes Air

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When Breath Becomes Air

by Paul Kalanithi

Forward by Abraham Verghese

ISBN 9780812988405 Random House, New York 228 pp

This author takes the reader with him through the terrible transition between his very ambitious and successful early life to his death as a 36 year old man– who gets lung cancer in the last years of his neurosurgery residency at Stanford. He had originally wanted to be a writer, but chose medicine instead. Yet he is still also a writer. As physician readers and reviewers, george meyer and I walked his walk not wanting to put the book down until the last word. Though Paul was unable to actually finish his book, he takes the reader to the point where he loses the ability to go on. His wife, Lucy, an internist whom he first met in medical school, provides closure in a touching epilogue.

The story begins at the ending…in the prologue. The author, previously treated for cancer, has recovered enough to nearly complete his 6th and last year of neurosurgery residency, when he develops extreme exhaustion and ominous symptoms. He pulls up and views his own CT scan with

‘lungs matted,… spine deformed, a lobe of the liver obliterated.’

Part I, 100 pages, could be of most interest to the non medically savvy reader. It tells of Paul’s life, from childhood through his years in medical school. Most interesting is that even while young he is concerned about life and death. That interest is sharpened later by patient care and by the death of his best friend. His writing is filled with pithy literary quotes, reflecting his extensive reading as a child and young man; and perhaps, great intimacy with his browser.

His portrayal of medical school and his experiences with patient care will be familiar territory to most physicians, and informative to others. He nicely portrays many of the challenges and contradictions medical students deal with as they progress through their training. Paul talks about the difficulty all of us (most of us) had with our cadavers and of the depersonalization we may develop so we are not too emotionally involved with the bodies we dissect. He describes the struggle of first-year residents who are fighting just to keep their heads above water. He worries that he was on “the way to becoming Tolstoy’s stereotype of a doctor”, dealing with the demands of residency, then practice, filled with the taste and smell of life and death while dealing with the ‘drama’ of the hospital, and administrators. It seems, though, that Paul develops a sense of who he is and what he stands for sooner than many of us do. He professes great sensitivity to patients and their families in the most trying of circumstances. He gets involved…intimately and actively, with patients, something often considered bad form or dangerous.

Part II, titled Cease Not Til Death, will likely be most meaningful to physicians, our friends, families, and other medical professionals. It is headed by this quote from Montaigne: study philosophy is to Learn to Die”.

Paul, the physician, becomes the patient. He describes his years long struggle, both mentally and physically, fighting his malignancy. During a tenuous remission he is able to complete all the demanding requirements of his neurosurgery residency. He writes of the experience during diagnosis, chemo, recovery, mental rigors, and recurrence. Both he and his wife are high powered high pressure professionals, and the marriage is stressful and long distance; yet the cancer changes that, bringing them more together. Paul’s long drawn out dying also intimately involves his oncologist, who helps him consider and make crucial decisions. All their intertwined lives are changed.

This book– short by comparison with so many that are far less informative– is well worth reading both by medical professionals, and by the general public. The former often look into the eyes of death, and the latter will at some time… It seems likely neither will escape life without that encounter.


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It’s that I suffer from xenofilia. I want to see and to know the entire world: people, languages, customs, lands, seas, deserts, forests, mountains. But I realize that if everyone is your brother, who is your brother. And if every land is your home, where is your homeland. So my true home is Northern California; I always return here, and perhaps here I shall die.

To judge from places I’ve lived over the years, I am 25% Chileno, 10% Mexican, 5% Panamanian, 10% Canadian, 1% Peruvian, 1% Brazilian, 1% Uruguayan, and 1% Argentino, and the rest USA. What irritates me most about my Americas are nationalisms, borderisms, racisims, and sexisms. Xenofiliacs are allergic to all.
Es que tengo xenofilia. Quiero ver –y quiero conocer –a todo el mundo: los pueblos, los idiomas, los costumbres, las tierras, los mares, los desiertos, las selvas, las cordilleras. Pero reconozco: si todo el mundo es su hermano, quien es su hermano; si todo el mundo es su tierra, donde es su tierra. Por eso mi tierra es norte-california, aquí vuelvo siempre, y espero quizás me muera.

De acuerdo a donde he vivido soy: 25% chileno, 10% mexicano, 5% panameño, 10% canadiense, 1% peruano, 1% brasilero, 1% uruguayo, 1% argentino. Lo que mas me irritan de mis américas son los nacionalismos, los fronterismos, y los racismos; y los sexismos. La xenofilia causa un rechazo total a todos.
E que tenho xenofilia. Queiro ver —y queiro conhecer– a todo o planeta: a gente, os idiomas, os costumares, as terras, os mares, os desertos, os bosques, as montanhas.
Mas intendo que si todo o mundo e o suo irmão, quem e suo irmão; si todo o mundo e a sua terra, onde e a sua terra. Por isso a terra central mia e o norte de Califórnia. Aqui volto sempre. Aqui moro, aqui espero morrer. De acordo com as mias residências, só 25% chileno, 10% mexicano, 5% panamenho, 10% canadense, 1% peruano, 1% brasileiro, 1% uruguaio,1% argentino. O que mais dor tem das américas, só os nacionalismos, fronterismos, racismos, y os sexismos. O xenofilico tem alérgia a todos.
Así confieso mi xenofilia, con disculpas por mi pobre portugués do Brasil; y mi ignorancia de los idiomas indígenas,–a pesar de que soy miembro del cuasi extinto tribu Concow del Norte de California.

So I confess my xenophilia, with apologies for my poor Brazilian Portuguese,, and, for my ignorance of indigenous languages. despite being a member of the near distinct Concow tribe of northern California,

Isso e o meu xenofilia, com desculpas por mi pobre portuges do Brasil, y mi ignorância dos idiomas indgeneas,– a pesar de ser parte do quasi extinto tribu Concow do Norte California.


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 She labors as we wait

She’s premature. It’s late.

Time’s thick tongue dryly licks

Her lips; 0436.


The cervix, not complete

Holds a butt and little feet

There’s no cord, heart rate fine

I worry, bide my time.


Four people, one a fetus,

wait for day to greet us.

Morose, I begin to dwell

On what there is to tell


Of Mestizo Amerinds

Whose trouble never ends

In this our tortured land

Far South the Rio Grande,


How a child might survive,

To keep its i alive

Unfed, untaught, but still

Fly North on wings of will.


I spend my little life

With death and birth and strife

And when the poor can’t pay

Stroke the rich to save my day,


See somber children grow

Like years, they come and go,

Speaking countless whys,

And not so simple lies.


Then wonderwords arrive,

As ‘Why am i alive?’

Or ‘where was i then?

‘Will i be me again?’


Answers, unpersuasive,

Seem lies or are evasive;

Except a newborn’s i,

Each word’s a subtle lie,


Fluid as a bat in flight

Whose image defies sight,

Or the quantal ‘where’,

That seen is never there,


Or dreams where we surmise

That we are all alive.

Past, future, even time

No one can quite define.


My God! She is complete!

Unblock the arms and feet;

Pull the face, and curse;

Ask pushes of the nurse!


And with a lusty cry,

There comes another i

Into a newborn day

To blow my words away.