On His Deathbed, Dr. Paul Kalanithi Warned of Physician Burnout

I avoided reading “When Breath Becomes Air.”

In Paul Kalanithi’s New York Times op-ed, the precursor to that best-selling book  on meaning, life, and dying young, he revealed his Stage 4 lung cancer diagnosis and how he was coming to terms with putting himself through hell for ten years of medical school and neurosurgery residency, only to learn he would not get to be a surgical professor after all.

At first, I did not realize that I knew the author of the op-ed –I only knew that he was a resident at Stanford Hospital.  I looked up a photo.

Wait–Pubby.

I did know him, but I had not known his real name. We had overlapped in college. Parties at our house, a green Craftsman that Stanford confiscated from an unruly frat and made available for co-ed housing, brought him over. His girlfriend, the house social director, told us about him in bits and pieces in between.
“We don’t sleep very much,” she coquetted during finals week, smiling. She was smitten, and who wouldn’t be? He was well-dressed, relaxed, handsomer than the other Indian-American men on campus. And he had a great (nick)name.

He had the easy confidence I had long associated with Indian-American Christians. When you grow up in a small town, belonging to the church bonds you to the community, the other kids have something in common with you. He would have been the high school student sipping whiskey in a park and talking about “On the Road” and life with a tight-knit circle of friends, actually enjoying the American high school experience instead of shuttling from math club to ACT tutoring like some kind of brown zombie. He did not seem to goof around much, but exuded a quiet intensity, much more tech-guy or literature professor (as it seemed he once aspired to be).

That’s part of why I didn’t picture him when I read the op-ed. He’d never had that nervous, soul-eaten pre-med anxiety.

That guy?? He was too cool to be a doctor.

Suddenly, I felt the same headache I had felt when I learned that a brilliant and kind engineer from my freshman dorm had died in his twenties, of prostate cancer.

Pubby—Paul–died before the book was complete, and his physician wife, Lucy, stepped in to do the rest. I avoided it as it gained more and more press, sat atop the bestseller lists. I avoided it until my local Stanford alumni book club put Paul on their list for 2016. I could not sip wine and eat Christmas cookies there, not without facing his words.

I knew I would be angry reading the book–just not that it would happen on page 6, when he gets blown off by a doctor who misses the diagnosis. It is difficult to understand doctors who see concerning symptoms and succumb to confirmation bias, especially when someone who, by definition of his job and hospital affiliation, is one of the most intelligent and rational people on Earth–says he might have cancer.

 

In the glow of an impeccably dressed Christmas tree, the book club was also indignant, but for different reasons.

“I felt like I didn’t really get to know him. He seemed so distant. The book was all about him but there was so little about his family.” said one woman, frowning.

“Yes, he wasn’t very emotional until the very end,” said another.

“36 hours in the operating room after a cancer diagnosis? Who DOES that?” asked a man.

Another woman said, admonishingly, “Maybe if he hadn’t been working so hard, he would have lived longer. Maybe going back to work killed him.”

No, I thought. I’ve taken care of young men and women in their 20s—nonsmokers–with lung cancer. It’s a nasty, nasty disease.

Most of the members of the book club had majored in the humanities; I was the only physician. I raised my hand and ventured, “I knew him—a little.”

I talked about how I remembered him, a healthy 22-year-old. I talked about the switch that goes on in your brain when you do surgery that tunnels your vision and attention down to a centimeters-square area of tissue, how everything else falls away or fades into the background. And how happiness and gratification get delayed, delayed, delayed, over years and years of ringing pagers and no sleep and death after death during neurosurgery training, all you have—literally, all you have in the world—is the promise that if you just keep working, you will be called a brain surgeon at last, and maybe take your spouse to that nice Palo Alto restaurant you could never afford before, not with your high rent and low income.

We had read the same book, yes. But I could feel the thump as he described collapsing on the floor after a long shift. All doctors have done that. The brief moments of marital discord, which the book club felt were ludicrous as a cause for Paul and Lucy’s near-separation, I knew to be an allusion to night after night of frustration and loneliness for her, of guilt for him for putting her life in a holding pattern for the four years beyond her residency. I knew she waited and watched as friends started families, bought lovely homes, and actually got to talk to showered, awake spouses once in a while. I knew she had woken to pagers and cell phone calls at all hours of the night and eaten countless meals alone. For those strung out by this inhuman life, the tiniest argument can spiral into a hurricane.

Surgeons cannot be emotional people at work. There are too many people to pronounce dead and too many families for which one must be the strong ship’s captain. I could hear the screaming inside his head, at the staggering unfairness of watching colleagues take jobs he’d dreamed of for years. I felt his shock at the bizarre behavior of the Christian God (killing a neurosurgeon with the potential to do life-saving research seems counterintuitive from a spiritual standpoint). I understood that he probably felt weird guilt at failing his family by dying instead of becoming a prominent doctor. 36 hours in an operating room was his way of fighting cancer, of telling it, “I will continue helping people, despite you, despite chemo, despite everything.” “When Breath Becomes Air” as much as he embellished it with lovely literary quotes, reads like a horror novel for physicians.

I knew what Paul might say if he could respond to the book club. I didn’t write more details about my wife and family because I hardly ever saw them, not until I was so sick they had to take care of me. I’m a good surgeon because I can dial down my emotions—but they are there.

 

But in the current maelstrom of national discussion about physician burnout (i.e. working so much you lose your ability to care) and work hours in residency programs, what stands out to me most is that a man with cancer, losing weight, writhing in pain—walked among the best Stanford physicians for months with no one suspecting the truth.

The unfairness of his delayed diagnosis only adds to the inconceivability, yet this is the current reality of medicine. We get paid for being fast, not good. Done, not thorough. Why do a detailed back and lymph node examination when you can just type “probably back strain?” and send the patient out the door? And get a “production bonus” for seeing more patients?
“When Breath Becomes Air” should be part of this discussion. Even lying in his hospital bed, fingers riddled with neuropathy, Paul relayed another cautionary tale, one that should make us think about our family members and their medical care. He had figured out that a trainee physician had forgotten to order his chemo medication and would rather ride out his shift and transfer the task of getting it approved to the next doctor than do the work himself. This is burnout with a capital B.

At Stanford, I took a poetry class. A classmate of Paul’s, now a Grammy-winning composer, wrote one of my favorites. It was in the form of a speech given by a performer thanking everyone who had worked on his show. The last line was, “Goodnight all, and thank you!” The poem was a metaphor for death.

Goodnight Paul, and thank you.

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