Published on 03 February 2022

When Breath Becomes Air

Professor Joseph Sung
Dean, Lee Kong Chian School of Medicine

A while ago, I read a book entitled “When Breath Becomes Air” by Paul Kalanithi, a neurosurgeon in Stanford University. Paul was a talented person who graduated from medical school and enrolled into the neurosurgery programme of Stanford, and before he wrote the book, he had just been appointed Professor in Neurosurgery. This was after many years of hard work, in studying, in residency training and in academic pursuit. Finally, he got what he wanted in his hand: a faculty position in Stanford, in a medical specialty that he loved most. 

One day while working in the operating room, Paul felt a sharp pain in his back. He endured the pain to finish the surgery in agony, only to find out in subsequent radiological investigations that he had lung cancer that had already metastasized to his spine, a stage IV disease. The book is about him as a doctor, going through the process of dying. He received chemotherapy, radiation therapy and palliative therapy; from a healthcare provider to becoming a receiver. 

In his words, “Once I had been diagnosed with a terminal illness, I began to view the world through two perspectives: I was starting to see death as both doctor and patient”. He said in his book “while being trained as a physician and scientist had helped me process the data… it did not help me as a patient”. When I read this, I feel ashamed that in previous years, as a young clinician-scientist, I was fascinated by the advancements in technology, new drugs and the wonderful endoscopic therapy (I was a gastroenterologist). And I endeavored to conduct studies, mostly randomised controlled trials, to prove that the treatment works or does not work. What I cared most was the enrollment of patients into the study, the patient-informed consent was signed, the results came out clean and undisputed that my hypothesis was correct. A landmark paper would then be published, my citation index would go up, my H-index would climb. And my career would be heading in the right direction. 

There is nothing wrong with conducting a properly designed clinical study. There is nothing to be ashamed of for advancing the science and practice of Medicine. But where is the human patient? What is the value of life after this?

LKCMedicine Dean's Blog - Feb2022 entryAs Paul walked through the journey of a cancer patient, he realised that, albeit as a surgeon, he had to face his own mortality and try to understand what made his life worth living. Paul gradually become cognisant that “(T) the tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out.” As a young surgeon and faculty in a top medical school, he should have a wonderful career in front of him. He was planning to get married soon and would love to have children of his own. He had all his plans worked out already, but now… “I would have to learn to live in a different way, seeing death as an impossible itinerant visitor but knowing that even if I am dying, until I actually die, I am still living.” 
In 2003, after the stressful calamity of SARS, I noticed that my beat was not normal. I sensed a “missing pulse” or drop-beat once every three normal beats. It gave me the feeling of riding on a roller-coaster 24 hours a day. Besides the discomfort, as a physician, I knew that this could be a bad sign. Irregular heartbeats may leave a blood clot in my heart, and when it breaks off, small pieces of clots (emboli) in my circulation could give me a stroke. “I might die from it. Or even worse, I will become hemiplegic at the age of 45! I might become bedridden, need to be looked after by my family or nursed in a nursing home.”  For the first time in my life, I was scared. Because I was a doctor, I was even more scared. My clinical sense did not help to calm me down. My biostatistics (those p-values and 955 confidence interval) did not mean anything to me, me as a patient. What I needed to know was “what are my chances, and how can I get better”. Fortunately, after my cardiology colleague performed an echo, 24-hour ECG and MRI for me, he concluded that my premature beats were benign. My arrhythmia could be controlled with medication. Paul is right. “Science may provide the most useful way to organise empirical reproducible data, but its power to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honour, weakness, striving, suffering, virtue… is limited”.  

So, finally Paul died. He died one year after he got married. He died after his baby girl was born. The last chapter of his book “When Breath Becomes Air” was finished for him by his widow. When I read that chapter, I wept. I teared for his bravery to tell the story of his last journey. I was thankful that he was survived by his beloved wife and daughter, and his love for them. I was touched by his story realising that while every person has to go through this same path, not everyone can live a meaningful life. 

When breath becomes air, what would you have left behind in this world? Before breath becomes air, have you made every day, every hour, every minute count?