December 3rd, 2023

WHEN BREATH BECOMES AIR for the ages, a book review by Jim W. Vogele

WHEN BREATH BECOMES AIR by Paul Kalanithi (Publisher:  Random House) 2016 ISBN 9780812988406 [hardback]



What can one say that would do justice to this beautiful book?

As I just reviewed Atul Gawande’s excellent book, BETTER, and because Atul Gawande is a better and more insightful writer than I, here is Dr. Gawande’s cover-jacket blurb on Dr. Kalanithi’s book:

“Rattling, heartbreaking, and ultimately beautiful, the too-young Dr. Kalanithi’s memoir is proof that the dying are the ones who have the most to teach us about life.”

Think about that for a moment.

After the Prologue, which is addressed a bit further below, the first sentence of WHEN BREATH BECOMES AIR is:  “I knew with certainty that I would never be a doctor.” As it turns out, Dr. Kalanithi was destined to indeed become a doctor after all, but he was also a writer, husband, father, son, brother, colleague, mentor, confidante, and friend to so many. Synthesizing it all, the driving inquiry of Kalanithi’s undergraduate literary studies becomes the primary inquiry of his life in medicine as well:  “What makes human life meaningful?”  The culmination of the author’s career decision-making process occurred on a walk home “from a football game one afternoon, the autumn breeze blowing, I let my mind wander. Augustine’s voice in the garden commanded, ‘Take up and read,’ but the voice I heard commanded the opposite: ‘Set aside the books and practice medicine.’”

Dr. Paul Kalanithi was both a doctor and a writer. Sadly, after a decade of training to be a neurosurgeon, his life was cut short tragically at the age of 37, having received a diagnosis at age 36 with stage IV lung cancer. WHEN BREATH BECOMES AIR was written as Dr. Kalanithi confronted mortality with bravery and steadfast commitment to his family, his profession, and his patients.


A life lived to the fullest


I rarely if ever feel intimidated when approaching a writing project. And perhaps in writing about Dr. Kalanithi’s book I’m not so much intimidated as I am simply impressed. In any event, a reader knows one is dealing with a classic when it feels as if quoting from the book at hand seems to be the only way to portray both its scope and its heart.

There are so many great passages in WHEN BREACH BECOMES AIR, that you can open the book to nearly any page and find something memorable. The Prologue alone is so moving and emotionally charged that one wonders whether the rest of the book can live up to the promise? Well, it certainly does.

Some of the passages are pure poetry while others serve the functional role of providing context and enlightenment. For example, Dr. Kalanithi provides this description of neurosurgery training:

“Midway through residency, time is set aside for additional training. Perhaps unique in medicine, the ethos of neurosurgery – of excellence in all things – maintains that excellence in neurosurgery alone is not enough. In order to carry the field, neurosurgeons must venture forth and excel in other fields as well. Sometimes this is very public, as in the case of the neurosurgeon-journalist Sanjay Gupta, but most often the doctor’s focus is on a related field. The most rigorous path is that of the neurosurgeon-neuroscientist.”

            Besides countless insights into medical training (e.g., “In residency there’s a saying:  The days are long, but the years are short.”), Dr. Kalanithi’s empathy for his patients is evidenced throughout:  “Before operating on a patient’s brain, I realized, I must first understand his mind:  his identify, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end.”

Some of the most poignant moments, in a book filled with such, are the discussions with patients about diagnoses and treatments.  Given that the author himself was experiencing both – the role of the physician making a diagnosis and discussing treatment options, and the role of patient undergoing the same with his own providers – the book takes on a depth of meaning that few tales can match.

The story of medical education and treatment is leavened throughout with Dr. Kalanithi’s grounding in literature (recall, he had intended to be a writer). The Kalanithi family’s move from New York to Kingman, Arizona when the author was 10 (the author’s parents had earlier relocated from their birthplace in southern India to New York City) is particularly fraught when the author’s mother learns that the U.S. Census Bureau had identified Kingman as “the least educated district in America.”  She obtained a college prep reading list and her son commenced to work his way through it:  “The Count of Monte Cristo, Edgar Allen Poe, Robinson Crusoe, Ivanhoe, Gogol, The Last of the Mohicans, Dickens, Twain, Austen, Billy Budd . . .”  Later, Dr. Kalanithi’s older brother sends books home from college and the younger Kalanithi devours those:  “The Prince, Don Quixote, Candide, Le Morte D’Arthur, Beowulf, Thoreau, Sartre, Camus.”

Needless to say, the maternal Kalanithi’s efforts to ensure that her children were educated and prepared for college served them well. Ultimately, Dr. Paul Kalanithi earned a B.A. and an M.A. in English Literature and a B.A. in human biology from Stanford; followed by an MPhil in history and philosophy of science and medicine from the University of Cambridge, and graduated cum laude from Yale School of Medicine. Dr. Kalanithi was well educated to say the least and his learning is evidenced, without being ponderous, in WHEN BREATH BECOMES AIR.

Dr. Kalanithi’s narrative provides a plethora of insights and anecdotes relating to physician training and medical care generally. This includes a reasonably readable discussion of cadaver dissection, which Kalanithi describes as “a medical rite of passage and a trespass on the sacrosanct . . . Everything teeters between pathos and bathos: here you are, violating society’s most fundamental taboos, and yet formaldehyde is a powerful appetite stimulant, so you also crave a burrito.”

Dr. Kalanithi also provides some basic perspective on how and why medical students choose to specialize in the areas in which they do.

All of this, and more, is of great interest to a physician contract review attorney. But this book would have been, and is, worth reading even if in my entire legal career I’d never provided legal advice on physician employment contracts. WHEN BREATH BECOMES AIR is an honest and gorgeously-written exploration of life and death.




WHEN BREATH BECOMES AIR is a beautiful book.

While it may be unclear what such a book has to do with a California physician contract review, a Montana physician contract review, a Washington physician contract review, or an Oregon physician contract review, this book — as is typical with literary works set in the world of medicine that I read — is relevant, both as a practical matter and as a matter of inspiring one to strive for excellence in providing the best physician contract reviews on the west coast (and Montana as well).

As Dr. Kalanithi has his first child with his wife, and, ultimately, is surrounded by love as he gives love to those around him, he provides any number of answers to the central question of what gives life meaning.  That is perhaps the unstated purpose of every great book. And I cannot think of higher praise than to say that WHEN BREATH BECOMES AIR embraces the issue squarely and honestly. That is enough; indeed it is more than enough.