The Dual Citizenship of Paul Kalanithi: Doctor and Patient

Paul Kalanithi's memoir, When Breath Becomes Air, is at its best when it is not trying to be particularly profound.  And I think it is, paradoxically, more moving in its earlier parts — not that the story of Paul Kalanithi's diagnosis, treatment, and eventual death at 37 from lung cancer is told in a an entirely linear fashion, for it is not — perhaps because we get real flashes of what he must have been like as a doctor in these pages. Later, we learn oh-so-much-more about him as a patient.

I was particularly struck by Paul Kalanithi's matter-of-fact remembrance of his first medical visit for rapid weight loss and "ferocious" back pain.  Hoping to see a Stanford classmate, he ends up at this visit with a practice partner of his friend, someone who is a stranger to him.  Now we see the power balance start to shift. He is more deferential than he thought he would be to her price and scarce resource-sensitive decision to start with x-rays before considering the MRI he requests. "MRIs for back pain are expensive" he notes as an aside though, because he fears cancer, he is eager to escalate. 

Afterwards, he asks "Why was I so authoritative in a surgeon's coat but so meek in a patients' gown?" This question is all the more poignant in light of the fact that he, as a neurosurgeon, knew more about back pain than this unknown internist did.

Oh, if he had only lingered there. Was it the gown, so emblematic of the power differential? The lessened deference to another doctor when the encounter is between strangers? Was it his own sense that it was unwise to escalate too quickly and, if so, was it because he shared her concerns about price-sensitivity and resource allocation or his own anxiety about confirming his worst fears?

Ultimately, Paul Kalanithi receives his diagnosis and, as prognosis weakens, struggles with being patient and letting someone else (by now an oncologist) be doctor.

He went on to continue his neurosurgery practice for a while, after this first internist encounter and even later, and I have to wonder if it changed him as a provider, as it surely changed him as a person.

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