Literary Insights

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This is the foreword to the memoir When Breath Becomes Air by Paul Kalanithi.
Abraham Verghese, the author of the foreword, first met Paul Kalanithi in early 2014 after Kalanithi published an op-ed in the New York Times about living with terminal lung cancer.
Verghese was struck by Kalanithi’s intellect, writing ability, and commitment to medicine and patients. They discussed Kalanithi’s desire to write a book before his death.
Though they didn’t stay in close contact, Verghese admired Kalanithi’s writing in another piece published shortly before he died. He saw similarities to 17th century author Thomas Browne’s style.
Verghese attended Kalanithi’s memorial service after he passed away from cancer. The foreword provides high praise for Kalanithi’s memoir and reflects on getting to know him near the end of his life through his writing.

The passage describes attending a memorial service for a man named Paul who recently passed away from cancer. The narrator reflects on finding meaning and renewal in funeral rituals and getting to know the deceased through the stories shared by loved ones.

After the service, the narrator realizes they came to truly know Paul only after reading his book, which was deeply honest and thought-provoking. The writing took their breath away. The narrator encourages the reader to read Paul’s work to see his courage in self-revelation, and how he continues to profoundly influence others after passing through his words. Overall, the passage emphasizes finding renewed purpose and connection through memorializing the deceased.

The narrator is a medical resident who is about to complete his final year of training in neurosurgery. His long-term girlfriend Lucy wants to break up, saying she’s not sure their relationship will get better once he finishes his residency.
The narrator begins experiencing concerning symptoms like bad back spasms. He gets some tests done but they come back clear. He decides to go on a trip to visit friends anyway.
While on the trip, his symptoms worsen and he starts to suspect he has cancer. He cuts the trip short and gets a chest x-ray, which shows abnormal results.
He goes back to the hospital he works at and gets admitted as a patient. He realizes his dreams of becoming an attending physician are over as he now faces an uncertain medical situation as a patient instead of a doctor.

The summary focuses on the narrator’s medical situation deteriorating, his relationship struggles, and realization that his career path has been cut short by his illness. It provides context for the quotes while staying relatively brief.

The narrator grew up in rural Kingman, Arizona, exploring the desert with friends and learning about its many dangerous creatures through “country facts.” This included encounters with black widows, rattlesnakes, and other spiders and scorpions.
The narrator’s mother feared for her children’s future in the underperforming Kingman school system. To address this, she had the children read extensively from a college prep reading list, exposing them to classics. This fostered a love of reading and philosophy in the narrator.
The mother also took active steps to improve the school system, joining the board and advocating for AP classes. This paid off as the narrator’s friend Leo, originally discouraged from college, was accepted to Yale.
The narrator reflects on preparing to leave for Stanford while friends have already departed. He spends afternoons hiking in the desert, thinking until meeting his older girlfriend Abigail after her coffee shop shift. This signals his impending entry into a new phase of life in college.

The narrator is running late to meet their friend Abigail at the coffee shop where she works. When they arrive, Abigail gives them a novel called “Satan: His Psychotherapy and Cure” to read, saying the narrator only reads “high-culture crap.” The novel’s simplistic view of the mind as the brain intrigues the narrator and inspires them to study both literature and neuroscience in college.

Over their college years, the narrator splits time between academic studies and forging meaningful relationships through experiences like working at a summer camp. They view literature as illuminating human experiences and morality, while neuroscience provides insight into how the brain gives rise to consciousness. In their final year, the narrator visits a care facility for people with severe brain injuries and is disturbed by how families often abandon their relatives there despite the difficulties of care. The summary focuses on the narrator’s intellectual and personal journey in seeking to understand what gives life meaning.

The passage describes some formative experiences during the author’s medical training. As a student, they initially felt apprehensive about dissecting cadavers but came to see it as a normal part of medical education. They found cadaver dissection epitomized the transformation from solemn student to callous doctor.

The gravity of medicine’s moral mission weighed heavily on the author in their early days of medical school. They took CPR training seriously, hearing ribs crack as they practiced on mannequins. When first facing their cadaver, its deadness and humanness were undeniable, making the prospect of dissecting it seem unconscionable.

However, veteran surgeons treated the cadaver casually during a visit, reconstructing its medical history while leaning on its covered face. This helped normalize the experience for the author. Within a few weeks, the initial drama of dissecting cadavers dissipated as it became a routine part of their training. The passage reflects on some of the emotional challenges of early medical education.

The author recalls their experiences as a medical student dissecting cadavers in anatomy lab. They felt the need to distance themselves from the more macabre aspects by highlighting and joking about gruesome details.
They acknowledge the donors consented to their bodies being used, but it was still difficult not to see their humanity, like finding undigested pills in one man’s stomach.
Over time in the lab, students became desensitized and objectified the bodies, seeing them as just tissues and organs rather than human beings. This realization made some students feel guilty.
The author apologizes not to their cadaver but to the cadaver’s family, realizing how upsetting it would be to think of a loved one being dissected.
Medical school gave the author a deeper understanding of the relationship between life, death, and the important but difficult role of doctors who must confront suffering and death while healing patients.
A defining moment was witnessing both a birth and a death during their first obstetrics shift, showing the twinned mysteries of life and death in medicine.
The author is a medical student completing their rotation in obstetrics and gynecology. They are still learning and fears accidentally having to deliver a baby alone.
The resident, Melissa, briefs the author on their first patient, Elena Garcia, who is 22 weeks pregnant with twins and at risk of preterm labor.
Things progress smoothly at first but then the fetal heart rates drop, indicating distress. An emergency C-section is performed and the underdeveloped twins are delivered.
The author assists and observes their first surgery. They struggle with some of the technical skills like suturing.
The twins are very premature at 23 weeks and 6 days gestation and face serious health risks. The author is taken by how small and fragile they appear.
On their next shift, the author assists with a routine delivery. Towards the end they are brought closer to observe but are uneasy about the responsibility of actively assisting given their limited experience. The summary reflects on the difficulty of learning clinical skills versus just studying textbooks.

This passage describes several key events and experiences the author had during medical school that impacted their career choice and views on medicine. Some key points:

The author witnesses a difficult labor and delivery, seeing both life and death in childbirth up close for the first time. This shows the complexities of medicine.
They learn that decisions around emergencies like C-sections involve life-or-death judgment calls that are not easy to make.
The author supports keeping language in the Hippocratic oath prioritizing patients’ needs over physicians’ lifestyles/jobs, noting most classmates chose less demanding specialties.
The author is inspired by a pediatric neurosurgeon’s compassionate discussion with parents of a child with a brain tumor. This realization, plus neurosurgery confronting existential questions, leads them to choose it as their specialty.
Neurosurgery involves manipulating human identity and confronting what makes life worth living, presenting moral and intellectual challenges the author is compelled by.

So in summary, the passage describes formative experiences that shaped the author’s views on medicine’s complexities and led to their choice of neurosurgery specialty.

The passage describes the extremely challenging and demanding training of a neurosurgery resident. In the first year, residents mainly do paperwork but witness life-and-death situations. The author loses their first patient, an elderly woman who crashes after surgery. It is a sobering experience.

In the second year, the resident gains more responsibility for emergencies. They have some successes saving critically ill patients, which is emotionally rewarding. However, the 100-hour work weeks take a toll physically and mentally. Not all residents can withstand the pressure - one is unable to accept fault, while another leaves the field due to stress. Mistakes are made as judgment calls must be made about who can and should be saved. The training pushes residents to their limits as they take on immense responsibilities.

The passage describes a neurosurgery resident’s evolving views on their career and role as a doctor. They had initially been attracted to neurosurgery because it dealt directly with life and death issues and they thought this would give them a sense of transcendence.

However, during residency they became inured to suffering and focused more on technical skills than human relationships with patients. Several anecdotes are described where the resident failed to show proper empathy or prioritize patient concerns.

The resident began to fear they were becoming detached from the larger human significance of their work. They realized the importance of communication with patients and families, especially around end-of-life decisions, where technical skills are not enough and compassion is needed.

The resident refocused on forging human connections and covenants with patients to guide them through difficult decisions and experiences with understanding, care and respect, inspired by the example of their father in his role as a doctor. The passage is about the resident learning that technical medical skills alone are not sufficient and that caring for the whole human being is most important.

The passage describes a patient who was having seizures and was diagnosed with a benign brain tumor after a scan. Surgery would likely eliminate the seizures but carried risks, while lifelong antiseizure medications was the alternative.
The doctor could have simply listed the surgical risks, documented the patient’s refusal, and moved on. Instead, they gathered the family to calmly discuss the options. This helped the enormous choice seem more understandable, viewing the patient as a person rather than a problem.
The patient chose to have surgery, which went smoothly. She was seizure-free after recovering for two days at home.
Later passages discuss informing another patient, Mrs. Lee, that her symptoms indicated a brain tumor, likely cancerous. The doctor proceeds gently, taking cues from the patient and explaining the surgery and next steps over multiple conversations to ease the difficult news.
It describes the challenges and emotional toll of neurosurgery work, but also the reward of protecting patients’ lives and identities in critical moments. The openness to each patient as an individual is emphasized over just presenting medical facts.

The passage describes the experiences and reflections of a neurosurgery resident. It discusses how they began doing research in neuromodulation techniques to treat neurological disorders. Their mentor V was diagnosed with pancreatic cancer but survived after extensive treatment.

As a chief resident, the responsibilities and stakes are higher. The passage provides two examples of how minor technical errors can have major consequences. A boy’s brain tumor surgery damaged his hypothalamus, turning him violent and requiring institutionalization. In another surgery, turning on the current for an electrode caused overwhelming sadness, showing how precisely targets must be hit.

The passage conveys the immense pressures, long hours, and responsibilities residents take on. Success requires both technical skill and speed in the OR, while failures can have devastating impacts on patients’ lives. It highlights how neurosurgery requires excellence not just in the field itself but in understanding patients’ conditions and navigating complex treatment decisions.

Here is a summary of the key events:

The narrator is doing a neurosurgery with an attending to remove a brain stem malformation. It requires precision to avoid potentially paralyzing the patient.
During the surgery, the attending stops the narrator and points out that cutting just a few millimeters deeper could cause “locked-in syndrome,” paralyzing the patient but leaving them able to blink. The attending reveals he caused this unfortunate outcome during his third time doing the surgery.
The passage discusses the important responsibility of neurosurgeons, who must balance saving lives with preserving patient identity and what makes their lives meaningful, like language abilities. Damage to key language areas can result in inability to speak, understand language, or communicate at all.
As a medical student, the narrator encounters a patient with a brain tumor disrupting his speech area, so he can only speak in numbers. The patient desperately tries to convey a message to the narrator in numbers before dying.
The narrator prepares for a risky surgery to remove a large tumor covering key language areas. The patient insists on having it removed, despite risks. During the surgery, the patient constantly swears and demands the tumor be removed, enabling the surgery’s success through his atypical language pathway.
The narrator’s career is progressing well until he gets a call that one of his former co-residents committed suicide after a patient death, overwhelmed by guilt. The narrator reflects on the responsibility and vulnerability that comes with their profession.
The narrator is diagnosed with severe lung cancer at a young age. This was completely life-shattering and collapsed his carefully planned future.
He meets his oncologist Emma, who is one of the top in her field. She wants to focus on treatment instead of survival statistics.
After a week of deterioration, the narrator is discharged from the hospital much weaker. He struggles to adjust to his new identity as a patient.
At his clinic appointment with Emma, they discuss the treatment options - traditional chemotherapy or newer targeted therapies. Tests showed a PI3K mutation but its significance is unknown.
Emma lectures the narrator as she would another doctor, reviewing the data and options. But she avoids mentioning survival statistics. Two paths forward are discussed - traditional chemo or newer targeted therapies that have led to long survival in some cases.

So in summary, the narrator is devastated by his cancer diagnosis but finds hope in being treated by one of the top oncologists. Emma focuses on treatment rather than statistics and discusses options tailored to his genetic results.

The doctor is waiting for test results to see if the patient has a common EGFR mutation. If so, there is a pill treatment option instead of chemotherapy. Chemo is scheduled as a backup plan starting Monday.
The doctor lays out carboplatin vs cisplatin chemo options, recommending carboplatin which is better tolerated though possibly less effective.
Test results come back positive for the EGFR mutation. Chemo is canceled and the patient will take Tarceva pills instead.
The couple goes to a sperm bank to preserve the patient’s fertility before starting cancer treatment, which is an emotional experience.
The patient reflects on how his perspective and relationship with statistics has changed now that he is the one with terminal cancer statistics applied to himself. He mulls the complexity of hope.
At follow up appointments, the doctor discusses treatment progress but also existential issues of how the patient wants to spend his time and career given his altered life expectancy. Therapy is also recommended to help the couple process the changes caused by the diagnosis.

The couple is coping surprisingly well with the husband’s terminal cancer diagnosis, excelling at adjusting to the challenges it brings to their relationship and lives. However, the therapist cautions that this does not necessarily mean it will get easier over time as the disease progresses.

As a doctor, the man understands his prognosis intellectually but still struggles with uncertainty as a patient. Not knowing how much time he has left makes major life decisions very difficult, like whether to have a child. With his wife’s support, they decide to pursue parenthood to continue living fully rather than focusing on his mortality.

Undergoing cancer treatment and physical therapy himself gives the man new insight into being a patient. It is humbling and identity-shaping in ways he did not fully grasp as a doctor. Meetings with his therapist are important for feeling like himself again.

After the first scan on his new treatment, the man is relieved to see that the cancer has significantly reduced in size and spread, considered a success even if not completely gone. This boosts his physical strength and hope for more time with his family.

The author is a former neurosurgeon who had to retire from surgery after being diagnosed with a brain tumor.
He attends a reunion of his neurosurgery program where he feels out of place among his successful former peers who are living the career trajectory he can no longer have.
He is uncertain about his identity and future without neurosurgery. He starts reading literature about illness and mortality to make sense of his situation.
After strengthening exercises, a scan shows his tumor has slightly reduced in size. His oncologist says living 10 more years is not unreasonable. This gives him justification to try returning to surgery.
He works on building back his surgical skills and gets assigned his first case. He does well at first but faints from nerves. He continues practicing slowly to rebuild his confidence. The summary shows his difficulty readjusting to surgery after his illness but his determination to try returning.

The narrator is a neurosurgeon who was diagnosed with cancer nine months ago. After initial treatment, his cancer is now under control but he has ongoing health issues. He has returned to work but is limited in what he can do physically.

He redoubles his efforts to fully regain his surgical skills and responsibilities over several weeks. This is emotionally and physically draining but he perseveres, wanting to graduate residency on time. His strength and abilities gradually improve.

During this time, his values and priorities shift as he continues dealing with his illness and mortality. He questions what truly matters to him in his career and life.

He interviews for a prestigious professor job that would fulfill his prior career goals. However, it raises questions about whether that path still fits with how his illness has changed his perspective. He remains unsure of exactly how to move forward long-term given the uncertainty of his health situation.

The narrator had achieved his goal of becoming a top neurosurgery trainee, set to have a career as a surgeon-scientist.
However, one night the chairman drove him past the hospital, showing him the view of a frozen lake where faculty lived. The narrator realized he could never actually move there, as his cancer diagnosis meant his wife would be isolated if he had a relapse.
He realized cancer had changed his calculation for his career and life goals. He could no longer seek the highest trajectory as a surgeon-scientist given the uncertainty of his health situation.
This made him question what he truly wanted - to be a father, neurosurgeon, teacher? He didn’t know but realized he would have to forge a new identity.
Attending church one Sunday, he found passages mocking literal interpretations of scripture humorous. This was part of what brought him back to Christianity after being an atheist, as he realized science could not account for concepts like meaning in life.
He returned to Christianity’s central values of sacrifice, redemption and forgiveness, feeling they were compelling. The message of mercy trumping justice also resonated with him.
The narrator is a neurosurgeon who has finished his residency training. He notices a new tumor on his last brain scan before becoming a father.
He and his wife Lucy map out the next steps of biopsies, tests and chemotherapy. This will be tougher than his previous treatment and may end his career as a neurosurgeon.
On his last day as a resident, he completes one final surgery but makes a mistake that leads to a complication.
He leaves the hospital, ending his neurosurgery career. He meets with his oncologist Emma to discuss treatment options.
Biopsies show no targetable mutations, so chemotherapy is the only option. They discuss which chemotherapy agents to use, with the narrator leaning towards including Avastin despite mixed data on its benefits.
The story focuses on the narrator transitioning from being a doctor to becoming a patient, losing control over his future and fate due to the cancer diagnosis.
The patient is a doctor who was undergoing chemotherapy for cancer. He began having severe side effects like vomiting, diarrhea, and eventually kidney failure that led to ICU admission.
There was confusion over one of his medications (Tarceva) when a resident took him off it without consulting his oncologist. This may have exacerbated his condition.
In the ICU, there were many specialists involved but no clear leader/captain of the ship. The different specialists had differing views which caused confusion over the treatment plan.
The patient and his partner tried to keep track of everything happening but it was difficult given his fluctuating mental state.
His oncologist returned from being out of town and was able to provide clearer leadership and direction for his care. She informed him he was improving.
Earlier, the patient’s partner had offered to just act as his doctor rather than be involved in medical decisions, since he is also a physician. This summarizes the key events in his medical situation and care.

Here is a summary of the key events:

The narrator, who has stage IV lung cancer, is hospitalized again due to complications. Their wife Emma helps take charge of the situation and bring a sense of calm.
As the narrator drifts in and out of delirium, they reflect on facing uncertainty and relying on others for guidance. Their cancer treatment is on hold until they regain strength.
Their daughter Lucy goes into labor while the narrator is in the hospital. They are able to be present for the birth of their daughter Cady, holding her skin to skin despite being too cold themselves.
After being discharged, the narrator continues to weaken physically but finds joy in their daughter’s development. They discuss the uncertainty of their future with their oncologist Emma.
Though facing an uncertain medical prognosis, the narrator finds meaning in simply being present and watching their daughter grow. They reflect on living in the present tense rather than future planning, given the uncertainty of their situation.
The narrator hopes to leave some message of the joy and satisfaction their daughter brought them in their final days, as their main legacy, though they are unsure what exactly to convey to an infant daughter.
The passage describes the final days and hours of Paul’s life as he battles advanced cancer.
Paul develops a high fever which is initially treated with antibiotics in the ER. However, his condition rapidly deteriorates and he struggles to breathe.
He is placed on a BiPAP machine to help with his breathing but his carbon dioxide levels continue rising, indicating respiratory failure.
Paul discusses with his doctors and family whether he should be intubated or switch to ‘comfort care’ given his terminal cancer prognosis. He is unsure if intubation would allow him meaningful time.
After spending the night on BiPAP, Paul brings his infant daughter Cady to the ICU, hoping she can help make the hospital feel more like home in his final moments. However, his respiratory failure is worsening and intubation seems imminent. The passage ends with the medical team discussing Paul’s case outside his room.

The family was distraught as Paul’s condition rapidly declined. His oncologist was hopeful treatment could help, but doctors at the hospital were less optimistic. Lucy pleaded with them to clearly state Paul’s chances of recovery.

Paul told Lucy he was ready to remove life support and start morphine to die peacefully. The family gathered to express their love and support. Paul asked for his manuscript to be published. With Lucy by his side, he lost consciousness after about 9 hours and passed away peacefully.

Writing the book was very important to Paul as he wanted to help others understand death and mortality. He worked tirelessly on it even during his illness. The book captures Paul bravely facing his terminal illness and death. Paul and Lucy supported each other through difficult times, reconnecting in love during Paul’s cancer battle. Paul’s family also provided great comfort during his illness. The summary focuses on Paul’s decision to die and the family coming together during his final hours.

Paul faced his terminal cancer diagnosis and illness with grace, honesty, and openness. He allowed himself to grieve but also find purpose and meaning in the time he had left.
He wrote When Breath Becomes Air as a culmination of his love for literature and to share his experience of living with death. It became his new vocation after he could no longer practice medicine.
Paul is remembered fondly not just for his last days but for the whole of his life - his sense of humor, kindness, and value of relationships.
He was buried overlooking the Pacific Ocean, a place that symbolized ruggedness and honor. His grave is now visited often by his wife and daughter, who continue to grieve but also feel his ongoing love and presence in their lives.
Paul’s book has allowed him to continue helping others even after his death, fulfilling what he sought to do as a doctor. His wife is proud to have supported him throughout his illness and writing, helping ensure the book was published for others.
Paul faced death with integrity, courage and purpose, living fully to the end and finding meaning in the life he had. His story and voice through the book continue to impact many.

To advance lung cancer awareness and research, aiming to turn even advanced lung cancer into a survivable disease. The goal is to raise awareness of lung cancer and increase funding for research to develop more effective treatments that could allow patients to survive even advanced stages of the disease. Currently, lung cancer has a low survival rate compared to other cancers when diagnosed at later stages. Through advocacy and research support, the hope is that outcomes for lung cancer patients will continue to improve.

#book-summary

When Breath Becomes Air - Paul Kalanithi