When Breath Becomes Air

by Paul Kalanithi

  Cancer of the brain comes in two varieties: primary cancers, which are born in the brain, and metastases, which emigrate from somewhere else in the body, most commonly from the lungs. Surgery does not cure the disease, but it does prolong life; for most people, cancer in the brain suggests death within a year, maybe two. Mrs. Lee was in her late fifties, with pale green eyes, and had transferred to my service two days earlier from a hospital near her home, a hundred miles away. Her husband, his plaid shirt tucked into crisp jeans, stood by her bedside, fidgeting with his wedding ring. I introduced myself and sat down, and she told me her story: For the past few days, she had felt a tingling in her right hand, and then she’d begun to lose control of it, until she could no longer button her blouse. She’d gone to her local ER, fearing she was having a stroke. An MRI was obtained there, and she was sent here.

  “Did anyone tell you what the MRI showed?” I asked.

  “No.” The buck had been passed, as it often was with difficult news. Oftentimes, we’d have a spat with the oncologist over whose job it was to break the news. How many times had I done the same? Well, I figured, it can stop here.

  “Okay,” I said. “We have a lot to talk about. If you don’t mind, can you tell me what you understand is happening? It’s always helpful for me to hear, to make sure I don’t leave anything unanswered.”

  “Well, I thought I was having a stroke, but I guess…I’m not?”

  “That’s right. You aren’t having a stroke.” I paused. I could see the vastness of the chasm between the life she’d had last week and the one she was about to enter. She and her husband didn’t seem ready to hear brain cancer—is anyone?—so I began a couple steps back. “The MRI shows a mass in your brain, which is causing your symptoms.”

  Silence.

  “Do you want to see the MRI?”

  “Yes.”

  I brought up the images on the bedside computer, pointing out her nose, eyes, and ears to orient her. Then I scrolled up to the tumor, a lumpy white ring surrounding a black necrotic core.

  “What’s that?” she asked.

  Could be anything. Maybe an infection. We won’t know till after surgery.

  My inclination to dodge the question still persisted, to let their obvious worries float in their heads, unpinned.

  “We can’t be sure until after surgery,” I began, “but it looks very much like a brain tumor.”

  “Is it cancer?”

  “Again, we won’t know for certain until it is removed and examined by our pathologists, but, if I had to guess, I would say yes.”

  Based on the scan, there was no doubt in my mind that this was glioblastoma—an aggressive brain cancer, the worst kind. Yet I proceeded softly, taking my cues from Mrs. Lee and her husband. Having introduced the possibility of brain cancer, I doubted they would recall much else. A tureen of tragedy was best allotted by the spoonful. Only a few patients demanded the whole at once; most needed time to digest. They didn’t ask about prognosis—unlike in trauma, where you have only about ten minutes to explain and make a major decision, here I could let things settle. I discussed in detail what to expect over the next couple of days: what the surgery entailed; how we’d shave only a small strip of her hair to keep it cosmetically appealing; how her arm would likely get a little weaker afterward but then stronger again; that if all went well, she’d be out of the hospital in three days; that this was just the first step in a marathon; that getting rest was important; and that I didn’t expect them to retain anything I had just said and we’d go over everything again.

  After surgery, we talked again, this time discussing chemo, radiation, and prognosis. By this point, I had learned a couple of basic rules. First, detailed statistics are for research halls, not hospital rooms. The standard statistic, the Kaplan-Meier curve, measures the number of patients surviving over time. It is the metric by which we gauge progress, by which we understand the ferocity of a disease. For glioblastoma, the curve drops sharply until only about 5 percent of patients are alive at two years. Second, it is important to be accurate, but you must always leave some room for hope. Rather than saying, “Median survival is eleven months” or “You have a ninety-five percent chance of being dead in two years,” I’d say, “Most patients live many months to a couple of years.” This was, to me, a more honest description. The problem is that you can’t tell an individual patient where she sits on the curve: Will she die in six months or sixty? I came to believe that it is irresponsible to be more precise than you can be accurate. Those apocryphal doctors who gave specific numbers (“The doctor told me I had six months to live”): Who were they, I wondered, and who taught them statistics?

  Patients, when hearing the news, mostly remain mute. (One of the early meanings of patient, after all, is “one who endures hardship without complaint.”) Whether out of dignity or shock, silence usually reigns, and so holding a patient’s hand becomes the mode of communication. A few immediately harden (usually the spouse, rather than the patient): “We’re gonna fight and beat this thing, Doc.” The armament varies, from prayer to wealth to herbs to stem cells. To me, that hardness always seems brittle, unrealistic optimism the only alternative to crushing despair. In any case, in the immediacy of surgery, a warlike attitude fit. In the OR, the dark gray rotting tumor seemed an invader in the fleshy peach convolutions of the brain, and I felt real anger (Got you, you fucker, I muttered). Removing the tumor was satisfying—even though I knew that microscopic cancer cells had already spread throughout that healthy-looking brain. The nearly inevitable recurrence was a problem for another day. A spoonful at a time. Openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.

  Yet openness to human relationality also carried a price.

  One evening in my third year, I ran into Jeff, my friend in general surgery, a similarly intense and demanding profession. We each noted the other’s despondency. “You go first,” he said. And I described the death of a child, shot in the head for wearing the wrong color shoes, but he had been so close to making it…Amid a recent spate of fatal, inoperable brain tumors, my hopes had been pinned on this kid pulling through, and he hadn’t. Jeff paused, and I awaited his story. Instead, he laughed, punched me in the arm, and said, “Well, I guess I learned one thing: if I’m ever feeling down about my work, I can always talk to a neurosurgeon to cheer myself up.”

  Driving home later that night, after gently explaining to a mother that her newborn had been born without a brain and would die shortly, I switched on the radio; NPR was reporting on the continuing drought in California. Suddenly, tears were streaming down my face.

  Being with patients in these moments certainly had its emotional cost, but it also had its rewards. I don’t think I ever spent a minute of any day wondering why I did this work, or whether it was worth it. The call to protect life—and not merely life but another’s identity; it is perhaps not too much to say another’s soul—was obvious in its sacredness.

  Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight.

  —

  Midway through residency, time is set aside for additional training. Perhaps unique in medicine, the ethos of neurosurgery—of excellence in all things—maintains that excellence in neurosurgery alone is not enough. In order to carry the field, neurosurgeons must venture forth and excel in other fields as well. Sometimes this is very public, as in the case of the neurosurgeon-journalist Sanjay Gupta, but most often the doctor’s focus is on a related field. The most rigorous and prestigious path is that of the neurosurgeon-neuroscientist.
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br />   In my fourth year, I began work in a Stanford lab dedicated to basic motor neuroscience and the development of neural prosthetic technology that would allow, say, paralyzed people to mentally control a computer cursor or robot arm. The head of the lab, a professor of electrical engineering and neurobiology, a fellow second-generation Indian, was affectionately called “V” by everyone. V was seven years older than I, but we got on like brothers. His lab had become a world leader in reading out brain signals, but with his blessing I embarked on a project to do the reverse: to write signals into the brain. After all, if your robot arm can’t feel how hard it’s grasping a wineglass, you will break a lot of wineglasses. The implications of writing signals into the brain, or “neuromodulation,” however, were far more wide-reaching than that: being able to control neural firing would conceivably allow treatment of a host of currently untreatable or intractable neurological and psychiatric diseases, from major depression to Huntington’s to schizophrenia to Tourette’s to OCD…the possibilities were limitless. Putting surgery aside now, I set to work learning to apply new techniques in gene therapy in a series of “first of its kind” experiments.

  After I’d been there for a year, V and I sat down for one of our weekly meetings. I had grown to love these chats. V was not like other scientists I knew. He was soft-spoken and cared deeply about people and the clinical mission, and he often confessed to me that he wished he’d been a surgeon himself. Science, I had come to learn, is as political, competitive, and fierce a career as you can find, full of the temptation to find easy paths.

  One could count on V to always choose the honest (and, often, self-effacing) way forward. While most scientists connived to publish in the most prestigious journals and get their names out there, V maintained that our only obligation was to be authentic to the scientific story and to tell it uncompromisingly. I’d never met someone so successful who was also so committed to goodness. V was an actual paragon.

  Instead of smiling as I sat down across from him, he looked pained. He sighed and said, “I need you to wear your doctor hat right now.”

  “Okay.”

  “They tell me I have pancreatic cancer.”

  “V…okay. Tell me the story.”

  He laid out his gradual weight loss, indigestion, and his recent “precautionary” CT scan—a truly nonstandard procedure at this point—which showed a pancreatic mass. We discussed the way forward, the dreaded Whipple operation in his near future (“You are going to feel like a truck hit you,” I told him), who the best surgeons were, the impact the illness would have on his wife and children, and how to run the lab during his prolonged absence. Pancreatic cancer has a dismal prognosis, but of course there was no way to know what that meant for V.

  He paused. “Paul,” he said, “do you think my life has meaning? Did I make the right choices?”

  It was stunning: even someone I considered a moral exemplar had these questions in the face of mortality.

  V’s surgery, chemotherapy, and radiation treatments were trying, but a success. He was back at work a year later, just as I was returning to my clinical duties in the hospital. His hair had thinned and whitened, and the spark in his eyes had dulled. During our final weekly chat, he turned to me and said, “You know, today is the first day it all seems worth it. I mean, obviously, I would’ve gone through anything for my kids, but today is the first day that all the suffering seems worth it.”

  How little do doctors understand the hells through which we put patients.

  —

  In my sixth year, I returned to the hospital full-time, my research in V’s lab now relegated to days off and idle moments, such as they were. Most people, even your closest colleagues, don’t quite understand the black hole that is neurosurgical residency. One of my favorite nurses, after sticking around until ten P.M. one night to help us finish a long and difficult case, said to me, “Thank God I have tomorrow off. Do you, too?”

  “Um, no.”

  “But at least you can come in later or something, right? When do you usually get in?”

  “Six A.M.”

  “No. Really?”

  “Yep.”

  “Every day?”

  “Every day.”

  “Weekends, too?”

  “Don’t ask.”

  In residency, there’s a saying: The days are long, but the years are short. In neurosurgical residency, the day usually began at six A.M. and lasted until the operating was done, which depended, in part, on how quick you were in the OR.

  A resident’s surgical skill is judged by his technique and his speed. You can’t be sloppy, and you can’t be slow. From your first wound closure onward, spend too much time being precise and the scrub tech will announce, “Looks like we’ve got a plastic surgeon on our hands!” Or: “I get your strategy: by the time you finish sewing the top half of the wound, the bottom will have healed on its own! Half the work—very smart!” A chief resident will advise a junior, “Learn to be fast now. You can learn to be good later.” In the OR, everyone’s eyes are always on the clock. For the patient’s sake: How long has he been under anesthesia? During long procedures, nerves can get damaged, muscles can break down, kidneys can fail. For everyone else’s sake: What time are we getting out of here tonight?

  I could see that there were two strategies to cutting the time short, perhaps best exemplified by the tortoise and the hare. The hare moves as fast as possible, hands a blur, instruments clattering, falling to the floor; the skin slips open like a curtain, the skull flap is on the tray before the bone dust settles. As a result, the opening might need to be expanded a centimeter here or there because it’s not optimally placed. The tortoise, on the other hand, proceeds deliberately, with no wasted movements, measuring twice, cutting once. No step of the operation needs revisiting; everything moves in a precise, orderly fashion. If the hare makes too many minor missteps and has to keep adjusting, the tortoise wins. If the tortoise spends too much time planning each step, the hare wins.

  The funny thing about time in the OR, whether you race frenetically or proceed steadily, is that you have no sense of it passing. If boredom is, as Heidegger argued, the awareness of time passing, then surgery felt like the opposite: the intense focus made the arms of the clock seem arbitrarily placed. Two hours could feel like a minute. Once the final stitch was placed and the wound was dressed, normal time suddenly restarted. You could almost hear an audible whoosh. Then you started wondering: How long until the patient wakes up? How long until the next case is rolled in? And what time will I get home tonight?

  It wasn’t until the last case finished that I felt the length of the day, the drag in my step. Those last few administrative tasks before leaving the hospital were like anvils.

  Could it wait until tomorrow?

  No.

  A sigh, and Earth continued to rotate back toward the sun.

  —

  As a chief resident, nearly all responsibility fell on my shoulders, and the opportunities to succeed—or fail—were greater than ever. The pain of failure had led me to understand that technical excellence was a moral requirement. Good intentions were not enough, not when so much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimeters.

  One day, Matthew, the little boy with the brain tumor who had charmed the ward a few years back, was readmitted. His hypothalamus had, in fact, been slightly damaged during the operation to remove his tumor; the adorable eight-year-old was now a twelve-year-old monster. He never stopped eating; he threw violent fits. His mother’s arms were scarred with purple scratches. Eventually Matthew was institutionalized: he had become a demon, summoned by one millimeter of damage. For every surgery, a family and a surgeon decide together that the benefits outweigh the risks, but this was still heartbreaking. No one wanted to think about what Matthew would be like as a three-hundred-pound twenty-year-old.

  Another day, I placed an electrode nine centimeters deep in a patient’s brain to treat a Parkinson’s t
remor. The target was the subthalamic nucleus, a tiny almond-shaped structure deep in the brain. Different parts of it subserve different functions: movement, cognition, emotion. In the operating room, we turned on the current to assess the tremor. With all our eyes on the patient’s left hand, we agreed the tremor looked better.

  Then the patient’s voice, confused, rose above our affirmative murmurs: “I feel…overwhelmingly sad.”

  “Current off!” I said.

  “Oh, now the feeling is going away,” the patient said.

  “Let’s recheck the current and impedance, okay? Okay. Current on…”

  “No, everything…it just feels…so sad. Just dark and, and…sad.”

  “Electrode out!”

  We pulled the electrode out and reinserted it, this time two millimeters to the right. The tremor went away. The patient felt, thankfully, fine.

  Once, I was doing a late-night case with one of the neurosurgery attendings, a suboccipital craniectomy for a brain-stem malformation. It’s one of the most elegant surgeries, in perhaps the most difficult part of the body—just getting there is tricky, no matter how experienced you are. But that night, I felt fluid: the instruments were like extensions of my fingers; the skin, muscle, and bone seemed to unzip themselves; and there I was, staring at a yellow, glistening bulge, a mass deep in the brain stem. Suddenly, the attending stopped me.