When Breath Becomes Air

After finishing the American physician Paul Kalanithi's When Breath Becomes Air, my heart would not settle for a long time. On the WeChat Read app this book carries a recommendation score of 95.3% and is hailed as a masterpiece. As I write this, 55,000 readers have read it and more than 3,000 have reviewed it.

I do not know how many of those 55,000 readers are doctors, and how many are patients or family members. But I suspect that, whether doctor, patient or family member, almost everyone who finishes the book is, like me, left unsettled.

Paul Kalanithi held an MD from Yale University and was a gifted neurosurgeon and neuroscientist at Stanford. An Indian-American, he had earned dual bachelor's degrees in English literature and human biology from Stanford, a master's in the history and philosophy of science from Cambridge University, and then his MD with honors from Yale.

His interdisciplinary Ivy League background gave this neurosurgeon something different from other doctors. He was an idealist, drawn to medicine by the highest humanitarian spirit. He became a clinician, hoping in his work to unite science with morality.

In 2013, at only 36, Paul Kalanithi was diagnosed with late-stage lung cancer. From then on he had a dual identity: doctor and cancer patient. Kalanithi had once dreamed of becoming a man of letters; between seeing patients, he kept reflecting and writing. His prose is beautiful, and his essays reveal deep reflections on human nature, life and death, morality and medical care. The Washington Post and The New York Times published his work, making him a writer of global renown.

I read his When Breath Becomes Air and several times felt the urge to weep. His thoughts as a doctor, I have lived; his thoughts as a patient, I have not lived firsthand—but when my mother was racked by cancer, did that piercing grief ever spare me? My mother's illness completely changed the course of my life. I once wrote an article "Reflections on Life", written just after my mother passed away; that essay recorded in detail the transformation of my thinking.

Similar life experiences give me a very deep understanding of Paul Kalanithi. We both want to be good doctors, devoting ourselves to guarding patients' lives, but sometimes we cannot. As Kalanithi put it, people pursue perfectionism, but the real world is not perfect.

Jamie was a close friend of Kalanithi's, also a clinician. Young Jamie, worn out by repeated failed efforts to save lives, carrying a deep sense of guilt toward his patients, leapt from a rooftop and ended his life.

This grieved Kalanithi deeply. Many doctors have shared Jamie's thoughts. When one vivid life after another slips away before our eyes, that powerlessness and guilt are indeed enough to crush most people. A clinician must cross this hurdle and emerge from the chrysalis in order to serve patients over the long run.

Around five years ago I was in Dr. Jamie's state, my heart full of guilt toward patients; at times I even thought of ending my life. But that state did not last long—I pulled through. Two doctor friends of mine attempted suicide, fortunately unsuccessfully. Another capable colleague could not bear the pressure of oncology and switched to medical aesthetics.

Paul Kalanithi went through such a process himself, so his friend Jamie's suicide hit him very hard. His writing moved me and soothed me. In this world, cultures and nations differ, but the problems doctors face do not, nor does the inner journey they must travel. His words resonated with me.

As a lung cancer patient and a neurosurgeon, Kalanithi knew deeply what a doctor means to a patient. He kept thinking about how best to fulfill a doctor's duty so as to ease things for patients and their families. He faithfully recorded his own changing understanding at work—from an inexperienced beginner to a gradually mature specialist. Along the way he never stopped reflecting on human nature.

What makes a qualified doctor? While reviewing for my licensing exam, looking at the detailed syllabus, I sometimes cannot help wondering: if today's doctors were to reread these syllabi, would they feel ashamed? So many things the exam demands of a doctor, I rarely see any doctor actually achieve in real life. How many can say with a clear conscience that they have never betrayed the original heart and oath with which they entered medicine?

In his clinical work, Kalanithi kept asking himself these questions. The most critical was: do we actually see patients as flesh-and-blood human beings? Something he wrote struck me deeply: at first he equated patients with medical-record terminology; later, as he read a chart, a living person would appear before his eyes. Modern doctors have grown used to assembly-line work; for many patients, medicine is cold and heartless. Some doctors, for personal gain, disregard whether patients live or die, manufacturing more suffering for patients in order to make money, even destroying their lives. This is no longer a doctor treating illness; it is a demon committing crime.

On a patient's blog I once read her account of how she resorted to prostitution to pay for treatment. I happened to know this patient well. In that moment I felt as if struck by lightning, my heart aching to the extreme. The patient has since died, and I have wept quietly for her fate. When I dug into the world she came from, I found other patients' family members also turning to prostitution to raise money for their loved ones' treatment. It grieved me deeply and made me wonder whether medicine is doing evil or good. We Chinese often speak of the physician's loving heart, but in reality our medical care has been distorted to the point of disgust.

A thousand readers reading When Breath Becomes Air will have a thousand reactions. For me, this thin book delivered an enormous psychological impact. It triggered yet another deep reflection on medicine and human nature. Recently a doctor at a Hunan hospital was thrust by public opinion into the eye of a storm. I was shocked that a medical school once so famous in China could produce such a doctor; at the same time I warily examined my own conscience, wondering whether some of my own actions were of a similar nature.

The loss of humane thought has led to a deficit of humanitarian spirit that has become a chronic ailment in today's medical world. Medical education cannot omit the education of the doctor's soul. If we treat patients as cold charts rather than treating each chart as a flesh-and-blood human being—someone with family who loves them, someone whose nearest and dearest would sacrifice everything to save them—we have strayed too far from medicine's original purpose. The rising tide of doctor-patient disputes has much to do with medical care no longer warming people's hearts.

Paul Kalanithi's father was also a doctor. Kalanithi recounts one detail of how his father served patients. When a patient was in low spirits, his father asked whether she would like him to order some food so she could fill her stomach first; she agreed. He asked what she wanted to eat; she said anything would do. He suggested some options, got her consent, and ordered the meal for her. Reading this, I was moved. Of course, doctors in China carry a far heavier workload than their American counterparts and may find such detail difficult. But a doctor who wants to warm patients in small ways, ease their discomfort, and build trust between doctor and patient will never lack opportunities; what we may truly lack is the heart to treat patients well.

I read this book in a spirit of self-examination, because in reading it I discovered many problems in myself and many places where my own work falls short. Alongside it I read textbooks such as Doctor-Patient Relationship. But textbooks are cold and rigid; some of their dogma is mere official boilerplate that cannot be put into practice. When Breath Becomes Air is a living textbook, and it taught me more.

Kalanithi's book made me want very much to say sorry to some of my readers and patients. In communicating with them, I could have done better, but I did not—all because I was not yet mature enough.

Paul Kalanithi has unfortunately died of cancer, but the spiritual legacy he left did not vanish with his life. Among my readers are many fellow doctors. I hope that when you have time, you will read this book, and after reading, reflect: what must we do to count as a competent healer?