GeriPal Podcast #2: Breath Becomes Air or Nothing Becomes Something

Eric: This is GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Ken: Ken Covinski.

Alex: Part Two is a new segment that we are tentatively calling Tell Us What You Really Think. In this segment, we’re going to talk about reviews of the book When Breath Becomes Air by Paul… does anybody know how to say his last name?

Eric: I don’t think we can ask that question on the radio.

Alex: We’re just going to take a stab at it. I say Kalanithi, but I suspect that’s wrong. Listeners, please feel free to let us know in the comments to the GeriPal posts that accompanies this podcast how to pronounce this last name. Anyway, terrific book I thought and Eric thought according to his review in GeriPal. In brief, this book was about a neurosurgeon in training at Stanford who developed a metastatic lung cancer and died. I’m not giving anything away here by saying that he died. I think everybody knows going into the book that he died.

It’s about much more than that. It’s about him facing mortality as a doctor who cares for patients who have serious life threatening illness. It’s about the struggle throughout his life between his interest in the humanities and his interest in medicine. It’s about the relationship that he has with his wife who is also a physician and the challenges they’ve gone through as a couple given the intense dedication to neurosurgery that’s required during the training time, and the difficulty that it caused in their marriage.

I think both Eric and I thought it was extremely well written. It was moving for us personally because it resonated with our own experiences in medicine. Eric in particular talked about somebody that he knew during medical school who died at age twenty-eight and yet we have this scathing review by Tom Laqueur.

Tom Laqueur is a professor of history at Berkeley and I know him. I TA’d for him and I’ve guest lectured in his course on death, and once he even valet parked my car. They have very different views. Before we get to Tom Laqueur’s review though, I just want to open up to Eric and Ken who both read the book. We actually had a book club about this previously and see if they have any thoughts about the book that they want to share with our listeners.

Ken: I just loved it. I thought it was a great book. I was moved by it. I thought it was compelling. I thought it was filmed with pearls of wisdom. I just thought, you know, even though he wrote about the last year of his life, it was not a book about death. It was a book about life.

Alex: Eric?

Eric: Agreed. I actually thought it was a short book, so it was a very quick read. In that time, you got a sense of how hard it is to be living with a serious illness, the needs of people who are even within the healthcare setting as far as informational needs including palliative care needs. It was touching also at the end to see his wife’s writing about the illness as well.

Alex: Let’s turn now to this review by Tom Laqueur.

Ken: I’m sure he’s a nice guy.

Alex: I’m sure.

Ken: I’m sure if he valet parked my car, I’d think he was a nice person too, but I don’t like his review.

Eric: What did the review say?

Alex: He says he wasn’t moved by the book. It’s pretty obviously from the title. The book is called When Breath Becomes Air. Tom titles his review “Nothing Becomes Something”.

Tom, being a history professor, takes us through a history of what he calls pathography which is writing devoted to the experience of living with illness, and notes that throughout history there have been very little writing devoted to living with illness and the dying experience with some notable exceptions that he describes.

It’s only really since the mid twentieth century that we’ve had an increase in writing about illness, experience, and dying. Why wasn’t he moved by this book? He had several points… the first is he says he finds the author pompous and egomaniacally self-conscious in a search for meaning.

Eric: Can you say that about somebody who died?

Alex: Right. He did just die. That doesn’t sound very nice.

Eric: I guess that’s a book review.

Alex: It’s a book review.

Ken: I don’t know. We all have our moments where our ego takes over. I don’t understand why Paul Kalanithi was supposed to have hid that. I actually thought he came across as compassionate, kind, and a person who had flaws and dealt with them like all people. This was a book where he actually did not try to make himself look virtuous. He portrayed himself as he was with the words that he perceived them.

Eric: I guess I was a little torn about this one because in reading the book I was struck by, okay, here is a neurosurgeon. As I think about neurosurgeons, you know, sort of grandiose and thinks a lot of himself. I did feel like that critique landed a bit more, for me, than the others. A second critique is about that he’s a bad writer. He says having done so little of it, why should he be a good writer. He cites his example, a quote from the book, “A tureen of tragedy was best allotted by the spoonful,” Kalanithi pronounces as a way of saying that patients need to be told prognosis of their illness with discretion and a feeling for what they can absorb. Now I didn’t know what a tureen was. I had to go to Google. It’s apparently some sort of container that you serve soup in, but I got the idea reading that sentence.

Ken: I think Dr. Laqueur makes a common mistake. People in academics write where they think the quality of writing is to be judged by things like diction and the grade level of the writing, so that the more education you need to understand what you have written, the better your writing. If you writing can only be understood by somebody with a PhD, that’s much better writing than something that a lay person can understand.

I don’t think that’s the way most people without PhDs think about good writing. That good writing is actually about the impact on the people you’re writing for. Judging by the impact of Kalanithi’s book, that was high quality writing when person after person feels moved. That’s good writing.

Eric: We should mention this book is a best seller and it’s gotten rave reviews from other sources like New York Times, New Yorker.

Alex: His next critique is that … This is interesting because Eric in his review and Tom Laqueur in his review both quote the same passage, but they drew very different conclusions.

Eric: Oh.

Alex: The passage is, “Years ago it occurred to me that Darwin and Nietzsche agreed on one thing, the defining characteristic of the organism is striving. Describing life otherwise was like painting a tiger without its stripes.” Eric, I’m not sure. You want to say a little bit about why that passage stuck out to you?

Eric: I think the reason that I wrote about this is that it did have to do with a personal loss that I had when I had … One of my good friends in med school died very early-on after graduating from med school. It made me think of all the things that I would want to do with my life if I knew I had only a couple of years to live. Would I go through the experience I went through in med school? Would I do internship? Would I work as hard as I did knowing that I would not be in this profession long or that I could do a myriad of other things?

I think the thing that struck me most about this book is while there was some uncertainty around his prognosis, in his writing, you do get a sense that he knew that time was limited yet he continued to pursue a training in one of the most challenging fields in medicine, one of the most arduous fields in medicine. I think, for me, this line really captures the efforts that he put into his job, striving for what he wanted in life and how everybody’s desires differ.

We see that all the time during palliative care consults, during geriatrics. It is that everybody is so very different in what they would do if time were limited and this was just an opening to someone else’s viewpoint and I thought it was very moving.

Alex: Here is the contrasting perspective from Tom Laqueur who said, “It misses the point that Darwin and Nietzsche agreed only that the tiger having stripes is not it’s telos, but a purely contingent result of an uncaring cosmos. Nietzsche never actually read Darwin, but hated him because Herbert Spencer, whom he imagined spoke for him, insisted that life had a progressive trajectory.”

Ken: That on earth is he talking about?

Eric: I’m sure if I was a smarter person, I would understand what he was saying. It does, to me, miss the point of this phrase which is really that we all strive for different things. Again, I think that the moving part of this book for me was that despite having a terminal diagnosis, he continued on. Again, it was one of the most arduous trainings in medicine knowing that time would be limited.

Ken: Yeah. I think where Dr. Laqueur misses the point is he emphasizes too much, the Darwin and Nietzsche part. You’re talking about somebody who is trying to write a book with limited time, so he may not have had time to fully research all the writings of Darwin and Nietzsche. The keyword in that sentence was strive and that was a keyword of the book, of how he was striving to find meaning and value in the time he had.

I think part of the difference I might have with Dr. Laqueur’s review is he reviewed this book on a highly intellectual level, and this book was meant to catch you on an emotional level.

Alex: Yeah. Yeah, so when I mentioned to my wife that Tom Laqueur had written a scathing review, and I said she should read it because I feel like this is an important review to read because often we learn more from the critical reviews of books even if we disagree with them than we do from the praise-praise-praise reviews, my wife’s reaction was, “I don’t want to read it. This book, for me, was not philosophy. It was literature. This was literature. I love this book in the same way that I like literature that’s written well as well as somebody can given the constraints that they’re dying, and that it’s a beautiful love story.”

One of Tom’s other critiques of this is I think he thought the love story angle was overplayed. It was quite poignant to me and moving to me the way that his wife finished the book and told the last chapter of the story of his life because he couldn’t in the way that he had died.

Ken: Yeah. I thought it was not overplayed at all. I thought it was totally authentic, and totally real, and totally honest.

Alex: Yeah. That was actually one of the more moving parts of the book for me, that this was tragedy, that there was so much potential here that was lost and yet in the face of that tragedy he was striving to be better. That was the central message. I guess Tom Laqueur was looking for something from a life that had been lived to its conclusion. He says he wishes that …

It sounds like he wishes that Paul Kalanithi had a chance to grow old before he died so that he could reflect backwards with the wisdom of years, like an Oliver Sachs who also recently died this past year.

Eric: That would have been a very different story.

Ken: That would have been a very different story, yeah.

Alex: Should we move on?

Eric: Alex, why don’t you end us on a happy note?

Alex: All right, here we go. This one seems to fit with the book if not the review perhaps.

Alex plays “There are places I remember”, by The Beatles.