A Very Interesting Medical Book

I post this here having already put it in my “Reviews” website because I think it’s well worth reading and I take a slightly different message than most reviewers from it.

Kalanithi, Paul. When Breath Becomes Air. Random House, New York. 2016. NF;7/17.

I had a few mixed feelings about this very popular, and very good, book. I hope my swimming against the streams of sickness/death and the American physician isn’t all envy for this fine writer’s success, although nobody would envy his untimely death. Dr Kalanithi describes while trying to maintain humility his superstar status in neurosurgery training and enviable future as one of the best neurosurgeons in his country. No one could avoid emotion and fascination when he tells us he’d looked at hundreds of seriously abnormal x-rays and scans, but the one he now confronted was of himself.

He was a literary guy, encouraged as a child to read. Not only did he do that, but he took to heart the ideas he found in literature and philosophy and had a real philosopher’s curiosity. He even went into neurosurgery as a kind of physical experiment in philosophy of mind, after finding academic literature too political (and is it ever political). And unusually among physicians and just about everybody else, he saw science’s limits:

… Scientific methodology is the product of human hands and thus cannot reach some permanent truth… As strong as (reproducibility and objectivity) make its ability to generate claims about matter and energy, it also makes scientific knowledge inapplicable to the existential, visceral nature of human life, which is unique and subjective and unpredictable.

Wonderful. He was pleasingly Gawande-like picturing a feckless resident who promises to do an extra bit of work for him as a patient and then doesn’t, and critical care subspecialists arguing fine points of care over his dying body in the intensive care unit. He knew the profession is far from perfect.

But if we are looking for perfection, Paul Kalanithi, readers must conclude, came pretty dang close. The book is his epitaph. He was a fabulously gifted and industrious young doctor dying (and dead when the book is published) and giving us his “words (which) have a longevity (he does) not.” His girl child is a baby when he dies, and he finished his book with a wise and kind message to her:

When you come to one of the many moments in life where you must give an account of yourself, provide a measure of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.

When I try to understand my real feelings about this quite magnificent final act, it’s not Paul Kalanithi himself that keeps me from alternately crying and jumping up and cheering. It’s what he unknowingly embraced when he chose his very difficult career. I’m a doctor too, but one who doesn’t have to exert much effort to lay claim to humility. Lots of people I’ve treated have properly felt anger, sadness, disappointment, and contempt for my work. I was that feckless resident. The good things I’m accomplishing at the end of my career don’t add up to a hill of beans compared to decades of my arrogance and greed. But that bad performance is mine. I didn’t arrogate it, or any of the good I watch myself doing, from something mystical that has been encouraged in society’s imagination.

That imagination continues to see my profession with all its institutions and technology as something to be revered and to tiptoe and whisper in the presence of. It’s not just American. I also see it working in an emergency room in Vancouver. Patients there often seem to cast themselves in a real-life version of a movie the final scene of which offers the hospital, doctors, nurses, and masses of incomprehensible machinery as the last rite of passage. But I think this is worse in the United States. Even Paul Kalanithi was rushed to the emergency room and admitted to an intensive care unit on the day he died. Filled with cancer and obviously near death, experts and family were still debating whether comfort care would be appropriate. This, I’m happy to say, would be a rare scenario where I live.

I also count it a minor shame that that this brilliant polymath young man’s moving book is received as well as it has been partly because of a mystique of medical omnipotence.

Why do I feel this way? It’s got to look as I say like envy. It is, but not entirely. I want medical doctors to be astute, precise, and to struggle mightily to master the necessary skills. But I want us to find our greatest satisfaction from convincing people in terrible situations that somebody who could congratulate himself just for doing a good technical job is also working hard to share their pain. And to find ways for them to stay home at the end and do better in their minds and hearts than default to a chilly falsehood.

I like to think Paul Kalanithi would have agreed. Wonderful book, nearly-unique situation including the skill and determination to write it. 8.7/9.3

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 30 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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