MAY 25, 2016
PAUL KALANITHI — a skilled neurosurgeon, promising neuroscientist, loving husband, and new father — died from cancer last year at age 37. When Breath Becomes Air, the lyrical memoir of his life and death, has captivated readers, topping nonfiction best seller lists since its posthumous release in January. But there is an equally heartbreaking loss of another young and talented doctor portrayed in Kalanithi’s book, one that is especially troubling because it has received almost no commentary from reviewers or readers — despite being emblematic of a disturbing phenomenon playing out across American healthcare. Unlike the rare cancer that steals Paul Kalanithi, “Jeff” (the pseudonym Kalanithi uses for one of his closest friends from residency) succumbs to a more common cause of death, one that is particularly prevalent among physicians yet often remains invisible.
When Breath Becomes Air opens with a short prologue in which Kalanithi views the CT scan images that confirm his own widely metastasized cancer. This prologue is followed by a far lengthier section entitled “In Perfect Health I Begin,” which flashes back to describe his childhood, his decision to become a doctor, and his medical training at Yale and Stanford. It culminates with Kalanithi recalling how, just as he “reached the pinnacle of residency,” he received a call informing him that Jeff, who had recently moved to the Midwest to begin a prestigious surgery fellowship, has killed himself.
Kalanithi expresses to the reader what he can never say to his friend:
I wished I could have told Jeff what I had come to understand about life, and our chosen way of life […] Death comes for all of us. For us, for our patients: it is our fate as living, breathing, metabolizing organisms. […] But Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel […] We had assumed an onerous yoke, that of mortal responsibility. Our patients’ lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.
It is a poignant passage, Kalanithi’s tribute to the profound struggle Jeff presumably experienced. But then he and we turn the page, beginning a new section of the memoir that returns to the moment of Kalanithi’s own diagnosis, followed by a recounting of his transition from doctor to patient, and ultimately from life to death.
Why do readers not make more of Jeff’s suicide, despite the emotional and narrative significance Kalanithi gives it? Perhaps it is because there is something more discomfiting (and less seemingly heroic) in a death by suicide than in a death by cancer. Or perhaps it is because a gifted, young surgeon’s suicide is even more incomprehensible to us than a 37-year-old’s death from cancer. But as rare as Kalanithi’s cancer is, the biggest tragedy of Jeff’s death is that it isn’t rare. Suicide is all too common among physicians. On average in the United States, at least one doctor kills her or himself every day, the equivalent to losing the entire graduating classes of two to three medical schools annually (or more — because suicide tends to be underreported, the actual death toll is likely even higher). Male physicians die from suicide at a rate 140 percent higher than the general population. For female physicians, the rate is even higher, an astounding 230 percent. Physician suicide is so prevalent, and so devastating, that a recent conference co-sponsored by the American Medical Association, the British Medical Association, and the Canadian Medical Association included a psychiatrist-led workshop on caring for doctors who have lost a colleague to suicide.
Yet a veil of secrecy contributes to the prevalence of physician suicide, making it difficult for doctors to get the support they need to stay alive and well. Although When Breath Becomes Air is one in a recent wave of illness narratives by doctors-turned-patients, these accounts focus on physical ailments. Public reflections by doctors struggling with mental or emotional issues are far rarer. In “Silence Is the Enemy for Doctors Who Have Depression,” Aaron Carroll wrote candidly for The New York Times about his own past experience with depression, boldly breaking the silence that leaves so many doctors isolated. But even as he called for greater candor about physicians’ mental health needs, Carroll noted that he is lucky because his professional focus is pediatric research, a field in which he is less likely to be ostracized for his openness than physicians in other specialties. Even so, he reports “many colleagues still recoil when I talk openly about therapy” — as though being treated to prevent depression or suicide is in itself a personal and professional failure.
Despite this widespread impulse to distance one’s self from an emotionally and mentally suffering colleague, if we read Kalanithi closely, an important commonality between him and Jeff emerges. When Kalanithi first received his diagnosis, he felt that “the certainty of death was easier than this uncertain life,” a concise description of a suicidal impulse. Yet that is not an impulse to which he succumbed. Instead, he suddenly happened to recall a phrase from a Beckett novel he’d read in college: “I can’t go on. I’ll go on.” Repeating these words imbued him with an ability to determine how he would live the uncertain life of a cancer patient.
I can’t go on. I’ll go on. What is the space between those two declarations, the abyss that in a moment of acute despondence Jeff couldn’t cross? How could a barely recalled literary allusion afford Kalanithi such emotional and mental fortitude? Taken together, those two simple sentences remind us that life is illogical; that we are illogical; that fear, frustration, and fallibility are part of being alive; and that any one of us can choose to push forward with life anyway. They affirm what might in an instant of despondence seem impossible: that we can somehow be as determined to continue as, a moment earlier, we felt determined to cease. These seven succinct words say so much, but no more than Kalanithi, or any other lover of literature, would expect from a writer like Beckett. This is the truth at the center of Kalanithi’s account of his illness: “It was literature that brought me back to life,” he declares in When Breath Becomes Air, recalling how he voraciously read everyone from Montaigne to Woolf.
Proclaiming the resuscitating power of literature might seem odd in the realm of the surgeon-scientist, but not to those schooled in the humanities. The humanities are, after all, what make us human, because they allow us to make meaning of the world and our experiences in it, at our best and worst moments. That is the reason that Kalanithi spent so much of his final year reading and writing. It is the reason readers are moved by the literary legacy he left us. It is also why the suicide he writes about, and the many others like it, demand our attention. Suicide is an effort to not contemplate, to not dwell in the messy and seemingly overwhelming relationship between suffering, death, healing, and life. Much of modern medicine is an effort to cordon off those categories, to treat disease as though it is always a fight that can and must be won. Kalanithi instead finds in his illness an impetus for contemplation, and thus resists the impulse to choose the certainty of death — even as the course of the disease makes his own mortality all the more certain.
The humanities infuse this process, guiding how Kalanithi tells his story and how we receive it. He selects his section titles (“In perfect health I begin” and “Cease not until death”) from the opening of Walt Whitman’s “Song of Myself.” He frames a discussion with his oncologist in terms of the Virgin and the Dynamo, historian Henry Adams’s meditation on the ways that first religious faith and later technology transformed human culture. Just before the birth of his daughter, seven months after his initial chemotherapy had shrunk his tumor enough that he returned to performing surgery, he learns his cancer has spread. He ponders this devastating news by distinguishing between his pre-diagnosis life as that of a Shakespearean hero or Enlightenment individualist whose actions presumably govern his fate, versus being plunged by his diagnosis into a Greek tragedy. That comparison is a humanist’s way of recognizing that there are forces we are subject to that will always be beyond our control, a universal truth that nevertheless runs counter to much of what we expect of modern medical science.
Kalanithi is hardly the only physician to seize a humanist’s perspective, particularly in the face of death. In Being Mortal, another doctor-authored work currently holding steady on the best seller lists, Atul Gawande explores how physicians and other caregivers could interact more effectively with patients and their families to ensure that a person’s end of life is as meaningfully lived as possible. Stylistically, Kalanithi’s and Gawande’s books are quite different: Gawande writes more like a reporter, interweaving persuasive data points with the stories of providers and patients he interviewed, to make a case for improving the ways we deal with fatal illnesses and caretaking of the elderly. Nevertheless, Gawande begins his final chapter by turning to Greek philosophy. He recounts Plato’s Laches, a Socratic dialogue examining courage, a quality Socrates probes but resists defining. Although Gawande has surveyed the topic of how we die with a surgeon’s precision, at this moment he recognizes that what we need in the face of mortality — our own or that of someone we care for (either professionally or personally) — is something that the humanities, with their emphasis on reflection and their toleration for ambiguity and uncertainty, convey so well.
And yet we resist such approaches, training our own caregivers away from them. Kalanithi earned a BA and MA in literature at Stanford before applying to medical school. Although he always wished to return to this first love, he presumed it would not be for decades. Until his diagnosis, he felt the pressures of a medical career left him time for little else. Recalling this period with an unflinching candor, he acknowledges that only a few weeks before his initial diagnosis, he was so consumed by work, so emotionally withdrawn, that his marriage was faltering. “When I talk to you about feeling isolated, you don’t seem to think it’s a problem,” his wife Lucy complained. He insisted, “It’s just residency,” to which she responded, “Do you really think things will be better when you’re an academic neurosurgery attending?” Lucy, who is also a physician, understood there would always be another grueling career phase, always more professional demands that could take precedence over emotional well-being. Or at least there should have been, until cancer intervened.
The couple’s conversation reflects the troubling dynamic that plagues those who pursue medical careers, a dynamic that at its worst drives the rates of physician suicide. Students begin medical school with better mental well-being and lower rates of depression than other college graduates, but within two years, their mental health deteriorates significantly. Somewhere between one in five and one in seven medical students experiences clinical depression, a result of what is increasingly recognized as the hidden curriculum of medical education: fierce competition with your classmates, faculty emphasis on perfection (including teaching techniques than can involve hazing, humiliation, and bullying), and unspoken fear that showing any doubt or deficiency is tantamount to revealing a fatal flaw. And medical school is just the beginning. During the first year of residency, the rate of clinical depression rises to between one in four and one in three. Despite working within healthcare systems, a mere 22 percent of those who are depressed during residency seek help. The vast majority of residents resist treatment out of denial of their own condition, shame at what they perceive as a personal weakness, or fear of being professionally penalized.
Although residency is generally considered the most stressful part of training, Lucy Kalanithi’s insistence that completing residency wouldn’t automatically alleviate her husband’s emotional distress was well founded. A recent survey of mid-career physicians found that almost 40 percent of them experienced depression, and over six percent of the nearly 7,000 respondents had contemplated suicide within the past year. Suicide rates are actually higher among mid-career physicians than among residents. As Brian Goldman, an ER physician and author of The Secret Language of Doctors, succinctly put it in a recent medical school commencement address, medical students and doctors inhabit “a culture that implies you should strive to be perfect even though you’re human — one that encourages you to run from your feelings even though you can’t hide from them.” (The passage in which Kalanithi imagines what he might have said to Jeff bears the mark of this culture. At first he states, “Even if you are perfect, the world isn’t,” an emphasis on perfection he only barely amends by concluding, “You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.” As devastated as he is by his friend’s suicide, Kalanithi still cannot recognize the deadly nature of striving for an impossible perfection.)
Even doctors who don’t suffer from clinical depression find their work can take a heavy emotional toll. A 2015 study revealed that 46 percent of physicians are experiencing burnout — a rate staggering not only because of the number of people affected but also because only two years earlier, the same survey found the rate was under 40 percent. In an article ominously (although not inaccurately) titled “The Inevitability of Physician Burnout,” Anthony Montgomery, an expert on social and organizational psychology, makes the case that physician burnout is an unavoidable effect of current medical education and work environments, not just in the United States but throughout the world. The result is an invisible public health crisis. Close to one in 10 of the 20,000 physicians included in the 2015 national study ranked their burnout so high they are thinking of leaving medicine — a particularly worrying statistic given that the US already faces a shortage of between 46,000 and 90,000 physicians within the next decade.
Despite the impact of endemic physician burnout, depression, and suicide on all of us patients, perception of the medical profession from the outside has yet to catch up. Perhaps this cultural denial stems from the prestige we associate with physicians, and our disbelief that those who provide our care could be so uncared for themselves. Even as I have been researching and writing about how these problems are affecting medical students and physicians, I’ve mentored a recent Harvard graduate regarding his plans to apply to medical school. Somehow I still want to believe his intelligence, commitment, and empathy, which would be so beneficial to the profession, will protect him, even though such traits failed to protect Jeff.
Although efforts to address burnout, depression, and suicide exist, they remain frustratingly piecemeal. A few medical schools have made first- and second-year courses pass/fail, to reduce stress and emphasize mastery rather than competitive grade-ranking. The Healer’s Art is a 15-hour elective incorporating reflection and sharing, offered to first- and second-year medical students at scores of medical schools across the country to reconnect them with empathy and mindfulness. Brigham and Women’s Hospital provides a seven-session non-mandatory humanistic curriculum to first-year internal medicine residents, which includes a visit to Boston’s Museum of Fine Arts as well as discussions of topics like emotional resiliency and grieving for patients. Separate programs at the same hospital, designed to remove some of the stigma for mid-career physicians, offer peer support at times of high professional stress. A clinical trial involving nearly 200 first-year residents showed that four weeks of web-based cognitive behavioral therapy reduced (but didn’t eliminate) the rates of suicidal ideation. Stanford’s Balance in Life program, intended to address depression and suicide by focusing on both physical and psychological health, serves the school’s surgery residents — but not Stanford’s residents in other fields, nor its medical students or practicing physicians. Pennsylvania State University’s Milton S. Hershey Medical Center offers three-to-five session humanities mini-courses for mid-career physicians. A writer-in-residence at Massachusetts General Hospital uses literary texts and reflective writing to help physicians connect to the difficult emotional aspects of their work and stave off burnout. Well-intended examples abound — but the result is far from comprehensive.
In his analysis, Montgomery argues that because burnout is a systemic problem, alleviating it requires a wide-ranging redesign of how physicians are trained and expected to practice. Although burnout is not the same as depression, the thoughtful redesign of graduate medical education is also essential to addressing the root causes of medical student and physician depression and suicide, as a recent editorial in JAMA (the Journal of the American Medical Association) attests. The Accreditation Council for Graduate Medical Education recently convened a Symposium on Physician Well-Being to address burnout, depression, and suicide. But the resulting three-year timelines for developing best practices reflect how slow the process of transforming medical culture, like any culture, can be; in the meantime the human cost — for medical students, physicians, their loved ones, and patients — remains high. And while the ACGME may eventually make recommendations or even requirements of medical schools and residency and fellowship programs, even more far-reaching transformations will be required to address the emotional needs of physicians across their careers.
How feasible is such massive change? Perhaps the answer depends on how necessary we recognize it to be. There are dual tragedies in both Kalanithi’s and Jeff’s deaths: the human tragedy, in which a loved and loving person dies young; and the societal tragedy, in which the costly and limited resources invested in training a physician turn out to be squandered when that physician’s career is cut short, leaving far fewer patients served than would have been the case had the physician remained in the profession. Maybe it appears coldhearted to think of Kalanithi’s or Jeff’s death in terms of lost return on investment, rather than focusing only on their personal suffering and the suffering of those who loved and mourn them. But much of what is broken in our healthcare system comes down to dollars and cents. Addressing the systemic roots of burnout, depression, and suicide will depend in part upon making the institutions that train and employ doctors, as well as the private insurers and government programs that pay doctors, rethink the value of investing in the ongoing mental and emotional well-being of caregivers.
Grief, guilt, helplessness, exhaustion, inadequacy: whatever Jeff felt just before he died, these were emotions every medical student, resident, and physician experiences. Providing a language to speak about those emotions, cultivating a community in which to contemplate those emotions, and instilling a recognition of the universality of those emotions — long before the moment of crisis comes — is crucial. With the urgency of knowing he would likely die soon, Paul Kalanithi devoted his final months to producing a literary reflection on what makes even a foreshortened life meaningful, leaving a legacy from which we readers continue to benefit. Why shouldn’t all medical students and physicians have such periods of contemplation and reflection throughout their training and practice?
Jeff was clearly suffering acutely at the moment he believed he couldn’t go on. But as Lucy Kalanithi observed after her husband Paul’s death, the lesson of his illness, and thus of his book, is “that life is not about avoiding suffering. […] It’s about creating meaning.” Individuals are typically drawn to careers in medicine because they want to do meaningful work, yet the demands of medical school and the day-to-day responsibilities of working physicians can leave little time, structure, or support for the kind of reflection that is essential to “making meaning.” We’ve separated the work of medicine and the work of the humanities for too long. After all, the creation of meaning is most important during our inevitable periods of suffering — whether the suffering is a patient’s physical illness or a physician’s emotional anguish.
If cancer hadn’t waylaid Kalanithi, would he too have succumbed to stress and burnout, perhaps even depression or, at the most extreme, suicide? Reading his own words, it’s hard to imagine someone so thoughtful and dedicated becoming so overwhelmed. But his colleague was just as thoughtful and dedicated, just as promising, and was lost, quickly and young. The best of modern medicine couldn’t save Paul Kalanithi. Until we change medical education and practice, it also won’t save countless other Jeffs.
Lois Leveen is the author of the novels Juliet’s Nurse and The Secrets of Mary Bowser. Her work has appeared in The Atlantic, The Chicago Tribune, The Daily Beast, The Huffington Post, The New York Times, The Wall Street Journal, and on NPR.