When Breath Becomes Air

Type: Non-Fiction 
Genres: Memoir, Philosophy 
Rating: 5/5 (Life Changing)
Review:  Click Here to go read the review

The book summary and notes comes after the section on how the book changed me and my top 3 favourite quotes.

The Book in 3 Sentences

1. A neurosurgeon named Paul Kalananthi guides readers with poetic prose through his life, before and after his lung cancer diagnosis, all while making it clear that his life was marked by a search for understanding life, death, and meaning.
2. As Paul's future life with his wife and dream career start to fade he needs to figure out who he should be and what he should do with the reminder of his time.
3. Paul ultimately decides to go back to neurosurgery and works until he permanently collapses as it was his calling and what gave him purpose.

Impressions

• Amazingly poetic and easy to read
• Very Inspiring and tear jerking
• Highly exceptional writing

How I Discovered It?

After watching the "Decoding Bill Gates" documentary on Netflix, my friend and I decided we wanted to emulate Bill's love for books. We ended up going through Bill's reading list and tried to pick out as many books to read as possible. When Breath Becomes Air was the first book from the Gates reading list that we decided to try reading.

Who Should Read it?

• Anyone who works in healthcare or anyone who works as a caregiver.
• Those looking to examine their values, ideals, and their authentic self.
• Anyone who is experiencing existential angst.
• Those looking for inspiration regarding the search for truth and answers.
• Those interested in following a personal journey of discovery as well those interested in learning about what it means to live and die.

How The Book Changed Me

• This book has inspired me to question myself, through journaling, on whether or not I was living a life that was true to my values, ideals, and passions.
• It helped me appreciate all those around me even more.
• It made me not feel bad about choosing meaningful experiences over better career opportunities.
• My idea of what makes a doctor truly amazing changed.
  • Before I thought a a great doctor was anyone who was just good at diagnosing and treating patients.
  • Through Paul's lens, I learned that a great doctor is someone who provides a safe space for patients and who helps them transition from the life they once had to whatever lay on the other side after a traumatic disease or illness. In other words, the ideal doctor is one who protects their patient's identity and make sure that it's intact following any treatment.
• The book has also inspired me to pursue my passions as well as have to fun along the way with the people I cherish the most.
• The book enforced my belief that human relationships and experiences are what give life purpose and meaning.
• It made me realize that death is almost inevitable and it's impossible to know when it will come knocking. That said, you can't be cynical. You need to live despite of the obstacles.

My Top 3 Quotes

I honestly couldn't get it down to 3 quotes..........

• "Life wasn't about avoiding suffering"
• "If the unexamined life was not worth living, was the unlived life worth examining?"
• “even if I’m dying, until I actually die, I am still living.”
• “The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.”
• “You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.”

Summary + Notes

 Anything in quotation marks are direct quotes from the book or Shortform"
Prologue:

• Sets the scene for Paul
• Paul is a neurosurgeon resident experiencing back pains
• He is super close to graduating and becoming a neurosurgeon and professor
• Paul's tough schedule started putting a strain on his marriage
• He doesn't want to believe that he has cancer so he tries to ignore it
• Important scene: he tries to ignore his illness, but the pain is so intense that he lies on his side by the train station
• He comes back from a trip with his friends, to his doctor telling him he has lung cancer.
• Everything he worked for was coming to an end
• Prologue ends with Paul going into the doctor's room but this time as the patient and not the doctor

Part 1:

• We first meet Paul when he's just a high school student.
• Paul never wanted to be a doctor, but instead a writer.
  • His family was full of doctors including his dad.
  • His father moved his family to a tiny city (Kingman, Arizona).
  • His dad worked a lot and his mother was dedicated to providing an amazing educational upbringing for Paul and his brother.
  • He was reading 1984 by the time he was 10 and other college level books like Brave New World by the time he was 12.
    • We learn quickly that Paul loves literature because they served as his guide for understanding life.
  • Paul's mom became part of the school administration.
    • She organized teaching staff and lobbied for advanced classes and made the townsfolk feel like they had a chance.
  • Paul's high school girlfriend gave him a book called Satan: His psychotherapy and Cure by the Unfortunate Dr.Kassler.
    • The book was about the brain and how the mind was strictly a mechanical function of it.
    • It changed him and made him add biology and neuroscience courses to his college degree.
    • Paul was obsessed with understanding meaning. If the brain was responsible for operating human meaning, he wanted to learn more about it.
  • In college, he came to the conclusion that meaning was intertwined with morality and human connection.
    • He learned this through literature and also realized that studying life was not the same as living life.
    • Literature and philosophy gave Paul the ability to explore the significance of life and neuroscience helped him continue to learn how the brain related to significance.
  • During his first summer as a university student, Paul had the option to work as a scientific researcher or as a cook at a summer camp.
    • He was choosing between filling his brain with theories about meaning or filling his life with meaningful experiences.
    • He chose the camp even though his academic counsellors disapproved.
• Later on in his university career, Paul visited a facility that housed people with traumatic brain injuries with his neuroscience professor.
  • He found out that a lot of the parents stopped visiting the kids and was upset by this as he believed that everyone deserved people who cared about them.
  • His professor said that sometimes it was better if patients didn't survive , which made Paul angry.
  • That day Paul learned that the brain houses a person's ability to relate, connect, and make meaning of life.
    • When the brain is lost, those attributes are lost, which made Paul wonder if life was worth living once they were gone.
  • Paul decides to go after a Masters degree in literature at Stanford regarding how literature relates to meaning.
    • He realized that his Masters degree wasn't providing him with enough answers.
  • Paul realizes he actually wants to become a doctor as he believed physicians were the only people who could truly discover the physiological-spiritual man and seek answers from those facing life and death.
    • Professors thought he was crazy so he ended up studying history and the philosophy of science at Cambridge before getting accepted into medical school at Yale.
  • At med school he starts off really disgusted from cutting cadavers. He realizes that all doctors need to make the distinction between life and science.
    • Eventually he got to a point where he could cut open donors and not bat an eye. This change in himself  horrified him.
  • He eventually learned to not just view work as work.
    • Ex: A wavy line on an EKG wasn't just a heartbeat, it was life pulsing through a body.
    • Also learned that death can only be understood when you come toe-toe with it.
    • As a doctor, Paul served as the gatekeeper for a person to either live another day or be hit with universal fate.
  • During his third year of his residency, Paul did gynaecology and watched a pair of twins die from an emergency c-section.
    • He realized that doctors need to make very critical calls and that knowledge of medicine wasn't sufficient. He would need to gain wisdom and moral intelligence to walk the lines between life and death.
  • Paul ends up choosing neurosurgery as his speciality, one of the most demanding specialties there is.
    • He chose this based on watching a paediatric neurosurgeon discuss a child's tumour with the child's  parents.
    • He believed that neurosurgeons didn't just treat the brain. but also the spirit of the person.
      • It wasn't just about saving the physical life of someone but making sure they had a quality life saved.
      • "Patients are confronted with the meaning of life, and doctors can help provide the facts to help them discover the answer"
• Lucy and Paul got married and moved to Cali to start their residences (Paul went back to Stanford)
• Paul experienced many deaths in the first year of his residency and was constantly going back and forth to the hospital, sometimes even spending the night.
• By year 2 of his residency, he was working almost 100 hours a week.
• Paul believed that saving a person meant more than just having them simply exist, but having them actually  live.
• Soon into year 2, Paul started questioning his morality because he could simply talk about death and even witness death, while going back to eating his lunch.
  • There's a scene where they believed someone wouldn't make it and as he left the room he realized he had his ice cream in front of the body that couldn't be saved.
• Paul's morality came back when his friend from medical school died from a car accident.
  • Paul felt guilty for failing to see his patients as suffering individuals and for moving past his patients like a worker on a factory line.
  • "It wasn't sufficient to just be an excellent surgeon. I had to be an excellent physician, which meant guiding those in my care, including families to a place where tragedy can be comprehended."
  • After his friend's death, Paul tried to be a companion to patients and their families.
    • He wanted to take full ownership of every aspect of his patients' care just like his father used to.
  • Paul learned that human relationality required him to be honest but not overwhelming. Eventually, he learned how to be a person who could carefully guide people about their chances of survival and give them hope. He wasn't just another doctor spewing statistics out at his patients.
  • Paul's new approach was very taxing and he often found himself crying for no reason.
    
    • Despite how hard his job was, Paul never questioned the value in it.
  • Paul believed that being a neurosurgeon was an amazing calling but a terrible job.
    • "Being a neurosurgeon was a virtuous endeavour, not because of the lives I was able to save but because of the identities I was able to maintain."
    • "Before any surgical procedure was performed, I needed to get a sense of that person’s identity. I needed to know their mind, what they valued, what they lived for, what they could live without, and what they couldn’t. Taking on that burden is a costly venture, for success in surgery is not guaranteed. And in those moments, the ones where we fail, the guilt is immeasurable"
• Paul later decides that he wants to be a neurosurgeon-neuroscientist.
• He started work at a Stanford lab to develop neural prosthetics and research neuromodulation.
• After a year, Paul's lab supervisor, V, got pancreatic cancer.
  • Paul was surprised when V, someone he considered to be very amazing, asked if his life had meaning and if he made the right choices.
  • After a year of treatment, V came back and told Paul that his first day back was the first day the suffering he endured felt worth it.
    • This made Paul realize that he would never truly understand a patient's cost of living as a doctor.
• By Paul's final year, he became chief resident.
  • Stanford wanted to hire him as a neurosurgeon-neuroscientist to study what he wanted to.
  • He finally was starting to get a clear picture of how he fits into this crazy world and what his role would be.
  • At the same, Paul found out his friend Jeff took his owl life after one of his patients died due to surgery complications.

Part 2:

• Paul started feeling his life and identity as a surgeon slip away when he found out he had cancer.
• Even though Paul guided so many patients to their new future, he felt lost and aimless.
  • Paul was so used to death but he no longer knew how to address it anymore
• Paul's doctor, Dr.Emma Hayward, was thinking about how to get Paul back to work as quickly as possible.
  • Paul thought this was crazy because he thought he could forge a different path and just wanted a treatment that would work the best.
  • Paul's identity of a neurosurgeon was fading from him, but Emma was there believing that he could gain that identity back and that was very soothing to Paul.
    • Emma helping Paul regain a grip of his identity made Paul realize he didn't want to give up. He was always going to die at some point. Just because death appeared sooner than he thought didn't mean he should quit everything and stop now.
      
    • Paul always thought he was going to work as a doctor/scientist for 20 years and then transition to a writer.
      • The problem was that Paul didn't know how much time he had left and Emma wouldn't provide a number.
      • Paul had to determine what was important to him and what gave his life meaning. Afterwards, he could find ways to try and live that life in whatever way he could.
  • Nice line from Paul-"Doctors have no real gauge of what the sick go through until they become one of them."
  • After a couple of months of physical therapy Paul was able to get back to biking, which was something he really enjoyed as well socialize with friends.
  • Emma challenged Paul to examine his values and priorities, rather than think about chances.
    • Paul realized he wanted to be a father
    • Even though, Lucy and him didn't have a clear picture of the future, they decided to live despite of death and start a family.
  • After sometime on cancer treatment, Paul was starting to get better and the picture of his old life was starting to come back.
  • Paul went back to literature and read a quote from Samuel Beckett, that went on the lines of " I can't go on. "I'll go on"
    • "Everything became clear in that moment. Although I was dying, I wasn’t dead yet. I was still living, and the only person I knew how to be among the living was me. And who I was was a surgeon. I would find a way to be that person again, whatever that looked like now, until death said for certain I couldn’t anymore."-Paul
  • Eventually, Paul went back to neurosurgery.
    • On his first day he was doing great, until he started to feel dizzy and had to stop.
      
      • Paul's fellow resident had to finish the surgery.
    • Paul went back the next day and the day after that. Eventually, he got back to fully capacity.
      
    • Paul decided he had to prove to his advisors that he could be one of the best again.
      
      • He significantly increased his hours and reclaimed responsibility for all aspects of his patient's care.
        • Paul didn't think he was going to make it as his workload was making him physically suffer. That said, he found meaning in his duties and that helped ease the pain.
        • Paul was in denial about the future and just didn't know how much time he had left. He thought that when you don't know how much time you have, pretending that you have all the time in the world is the best course of action.
      • Paul got a job offer at the university of Wisconsin. It had everything he ever dreamed of. He was going to get high pay, great hours, professorship and the funding to conduct his neuroscience research.
      • He ended up not taking the job because Lucy would be far away from her support system. Paul thought that in case cancer ever came back for him, he didn't want Lucy to be stranded alone with their new child in a far away city.
      • Paul went back to work as a neurosurgeon resident for 7 more months now and was scheduled for his last scan. In that scan he found a new tumour on his lungs.
      • Paul realized that things were going to be harder than last time and that the time he thought he had left was shortened.
        • The next day he went back to the hospital and completed one last surgery as a neurosurgeon and then packed his things up and stashed away the things that made him a doctor and decided to figure out what to do.
      • Paul started chemotherapy and became significantly weak again.
      • On the day of his neurosurgery graduation, Paul became ill and had to go to the ER instead of his graduation ceremony.
      • Paul gradually deteriorated and got moved to the ICU.
      • Eventually, Paul lost 40 pounds and actions like holding his head up right and drinking water became taxing.
      • Lucy soon went into labour and Paul's daughter, Cady, was born.
      • Time becomes meaningless to Paul as he is simply just existing, but not "living"
      • Paul wanted to live long enough so his daughter would remember who he was.
      • Paul left his daughter a final message:
        • "When life dictates you gather the evidence of your worth, as it will at various times, remember that by living, you helped me live. It is of no small consequence that you brought a peaceful calm to my dying days, one like I had never known. The joy you gave me is enough, and never doubt that it was everything."

Epilogue

• Paul unfortunately didn't finish his book and died on March 9,2015. The epilogue was written by his wife, Lucy.
  • Paul's daughter Cady was 8 months old when he died.
• During Paul's last months, he focused solely on writing his book and spending time with his daughter and having friends visit him.
• The cancer in Paul's lungs eventually spread to his brain and shortened his life even more and lead to eventual neurological deficits.
• The doctors offered to put Paul on a ventilator, but he didn't believe that it was worth it as he would just be existing and not living.
• Surrounded by his family, he communicated his love for all of them and told his family to make sure his book was published.
• The doctors took the supplied oxygen away from Paul and injected him with morphine.
  • Paul eventually inhaled and breathed out his last breath.