Munching Apples: On Paul Kalanithi’s “When Breath Becomes Air” by Andrew Bomback



It’s been more than a year since I read When Breath Becomes Air, the memoir penned by neurosurgeon Paul Kalanithi as he was dying from metastatic lung cancer. More than a year since I sat in my living room, late at night, reading and re-reading the book’s final paragraph, a short message to his newborn daughter.

When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.

More than a year since I used my phone to take a photo of that paragraph and vowed to look at it every time I felt frustrated as a parent. Every time I felt like yelling. Or taking a break. Or envying a fellow passenger on an airplane, who’s sitting alone, watching a movie on an iPad. Reading a book. Eating candy. Sleeping.

Of course, I haven’t gone back to that photo and those words until now, when I’m trying to express something coherent about why this book was and is so important to me, to my wife, and to other doctors. The paragraph is still a difficult read despite its beautiful language. The commas, especially: 11 commas that force the reader to pause, absorb each and every word, understand what Kalanithi is trying to convey to his daughter. I like to think that no editor was involved with that paragraph, that the commas were Kalanithi’s to place, his final entreaty to life, to his daughter, to his readers, to his physician colleagues, to me. Slow down. Slow down. Slow down.

Kalanithi’s wife, Lucy, also a doctor, wrote When Breath Becomes Air’s epilogue, in which she describes her husband’s final hours. A few weeks after finishing the book, my wife, Xenia, and I went to a reading that Lucy Kalanithi gave at a nearby college. After the event, Xenia lined up with others in the audience to meet Lucy Kalanithi and get her book signed. I stood a few feet away, watching Xenia as she made her way up the line. After Lucy Kalanithi signed her book, Xenia started talking to her. I was too far away to hear their conversation, so all I could do was watch them, read their facial expressions, see Xenia burst into tears, then see Kalanithi stand up from her chair and reach across the table to hug Xenia. Both women eventually broke from this embrace, wiped away tears, smiled, and then hugged one last time, a much shorter, farewell hug.

“I’m so embarrassed,” Xenia said on the drive home. “I told her I was a doctor, and I was asking her a bit about her career, and how she was balancing things, and then she asked if I was married to a doctor, and then if we met during training, and that’s when I just lost it.” From what I could tell, Xenia and Lucy Kalanithi essentially said nothing to each other from that point onward. The communication was understood: their lives were on the same trajectory at one point, and now they weren’t. For this reason, I often wonder if non-physicians can absorb just how heartbreaking When Breath Becomes Air is, beyond its basic story of a brilliant young man who died too early. Yes, Kalanithi died young, but he also died just after completing his residency training, before ever being able to practice medicine on his own. He never had the chance to reap the benefits of years stuck inside hospital walls.

The only realistic part of the television show, Scrubs, was that the residents had no social life outside of the hospital. Residency consumes the doctor-in-training. Days off are spent catching up on sleep, and that sleep is filled with nightmares of patients who are crashing due to small, preventable errors. Routine, everyday things like showers and meals have to be scheduled around extreme hours spent in the hospital. Birthdays and weddings and baby showers are missed. Life outside the hospital feels artificial. Attending physicians, like me, reassure the residents who work beneath us that life does get better. More normal. There will be flexibility in your schedule, we promise. There will be time for making your own family, we boast as we show photos of our kids on our phones. You will be happy you chose this career, even if you’re not happy now, we console.

When I was applying for residency positions, I heard a statistic that 110% of the married residents at Johns Hopkins got divorced. The explanation for the percentage being over 100 was that a few residents got divorced, remarried, and then subsequently got divorced a second time. This was obviously a myth meant to capture just how grueling and intense the Hopkins experience was for housestaff. I knew it was a myth, and I wasn’t married at the time, but I didn’t apply to Hopkins. At the beginning of When Breath Becomes Air, Paul and Lucy Kalanithi are residents on the verge of separating. His cancer diagnosis brings them back together. Their decision to have a child, knowing that Paul will not survive to see her grow up, is rooted in the promises they’ve been given of a life that awaits them after residency. Paul wants to make sure that at least one of them has this life.

Xenia and I met during residency. We were miserable at work but falling in love at the same time, so we often look back on those years as less painful than they really were. We reminisce about midnight snacks in the hospital cafeteria, for example, about how great the chocolate cake was, forgetting about how exhausted we were shoveling plastic forks through that cake. We answer affirmatively to Charles Simic’s question (posed in his memoir, A Fly in the Soup), as do most of our fellow doctors who have somehow survived their training:

Is it true that one grows nostalgic even about the horrors as one grows old? Probably. I’m nostalgic about an August afternoon after the war. My mother, brother, and I were being escorted at gunpoint and on foot from one prison to the other. At some point we walked past an apple orchard, and our guard let us stop and pick apples. Not a care in the world. Munching the apples and chatting with the guard.

The highlights of residency, for so many doctors, are the moments spent munching apples. These moments aren’t obvious at the time. They become clear years later, when we’re not worried about money, or sleep, or our ignorance’s ability to hurt someone. They emerge when we have the luxury to reminisce, a luxury never afforded to Paul Kalanithi.

When Xenia and I invite our residents over for dinner, we ask them to arrive early, as close to 5 PM as they can make it, so they can eat dinner with our children. We tell them to dress casually. In nice weather, we barbecue and eat outside. When it’s cold, Xenia makes a Mexican-style buffet in our kitchen – tostada shells, refried beans, pickled onions, shredded lettuce, chopped tomatoes, crumbled queso blanco, fresh-from-the-food-processor salsa, and what the residents invariably call the best guacamole they’ve ever had. Xenia and I are putting on a show, trying to present the best possible version of the life we live. The life that will be yours in a few years, we hope this show communicates.

Paul Kalanithi had mentors. He mentions many of them throughout his memoir. He must have been at similar dinners. Drinking beers. Sipping wine. Walking around a large house and thinking that someday he would have this for himself and Lucy and their future children. He probably had to wake up at four or five the next morning. He might have had another drink, lingered over dessert, stayed for late night conversation, thinking he’d catch up on his sleep some other time. He had so much of it, at least in his head.

That final paragraph – its commas and its heartfelt message, how it made me cry many months ago when I first read it, and how it made me cry again today when I pulled it up from my phone’s camera roll for the purposes of this essay – is why I’ve recommended When Breath Becomes Air to so many people, doctors and non-doctors alike. But there’s another section of the book that I often think about, two pages in the midst of the memoir in which Kalanithi confesses the “moral slides” he’s made as a resident. While working trauma, Kalanithi and another resident, Jeff, invent a humorous short-hand to describe the extent of a head trauma.

“Is he a Wyoming or a California?” Jeff would ask, trying to determine how intensive his care plan should be. Or I’d say, “Jeff, I know his blood pressure is labile, but I gotta get him to the OR or he’s gonna go from Washington to Idaho – can you get him stabilized?”

This is immediately followed by a case vignette, a 22-year-old man crashing in the emergency room from a major head injury suffered in motorcycle accident. Kalanithi was paged out of his lunch – a Diet Coke and ice cream sandwich – to help. Tucking away his meager provisions behind an emergency room computer, he spends close to an hour trying, unsuccessfully, to save the man.

I slipped out of the trauma bay just as the family was brought in to view the body. Then I remembered my Diet Coke, my ice cream sandwich . . . and the sweltering heat of the trauma bay. With one of the ER residents covering for me, I slipped back in, ghostlike, to save the ice cream sandwich in front of the corpse of the son I could not. Thirty minutes in the freezer resuscitated the sandwich. Pretty tasty, I thought, picking chocolate chips out of my teeth as the family said its last goodbyes.

These honest recollections, confessions of how the mind and the body will grasp at anything to survive the residency years, how Kalanithi found his “munching apples” moments in the trauma bay with some harmless jokes and a soggy ice cream sandwich, are why I consider When Breath Becomes Air essential reading for any doctor-in-training, why I push the book on so many medical students, residents, and fellows. These confessions and their aftermath: A few pages later, Kalanithi recounts hearing the news that Jeff, his co-resident, has killed himself.  And not too many pages after that, Kalanithi begins his final message to his daughter.


Andrew Bomback is a physician and writer in New York.