When Breath Becomes Air



The X-rays looked fine. We chalked the symptoms up to hard work and an aging body, scheduled a follow-up appointment, and I went back to finish my last case of the day. The weight loss slowed, and the back pain became tolerable. A healthy dose of ibuprofen got me through the day, and after all, there weren’t that many of these grueling, fourteen-hour days left. My journey from medical student to professor of neurosurgery was almost complete: after ten years of relentless training, I was determined to persevere for the next fifteen months, until residency ended. I had earned the respect of my seniors, won prestigious national awards, and was fielding job offers from several major universities. My program director at Stanford had recently sat me down and said, “Paul, I think you’ll be the number one candidate for any job you apply for. Just as an FYI: we’ll be starting a faculty search for someone like you here. No promises, of course, but it’s something you should consider.”



At age thirty-six, I had reached the mountaintop; I could see the Promised Land, from Gilead to Jericho to the Mediterranean Sea. I could see a nice catamaran on that sea that Lucy, our hypothetical children, and I would take out on weekends. I could see the tension in my back unwinding as my work schedule eased and life became more manageable. I could see myself finally becoming the husband I’d promised to be.

Then, a few weeks later, I began having bouts of severe chest pain. Had I bumped into something at work? Cracked a rib somehow? Some nights, I’d wake up on soaked sheets, dripping sweat. My weight began dropping again, more rapidly now, from 175 to 145 pounds. I developed a persistent cough. Little doubt remained. One Saturday afternoon, Lucy and I were lying in the sun in Dolores Park in San Francisco, waiting to meet her sister. She glimpsed my phone screen, which displayed medical database search results: “frequency of cancers in thirty-to forty-year-olds.”



“What?” she said. “I didn’t realize you were actually worried about this.”

I didn’t respond. I didn’t know what to say.

“Do you want to tell me about it?” she asked.

She was upset because she had been worried about it, too. She was upset because I wasn’t talking to her about it. She was upset because I’d promised her one life, and given her another.

“Can you please tell me why you aren’t confiding in me?” she asked.

I turned off my phone. “Let’s get some ice cream,” I said.



We were scheduled for a vacation the following week to visit some old college friends in New York. Maybe a good night’s sleep and a few cocktails would help us reconnect a bit and decompress the pressure cooker of our marriage.

But Lucy had another plan. “I’m not coming to New York with you,” she announced a few days before the trip. She was going to move out for a week; she wanted time to consider the state of our marriage. She spoke in even tones, which only heightened the vertigo I felt.



“What?” I said. “No.”

“I love you so much, which is why this is so confusing,” she said. “But I’m worried we want different things from our relationship. I feel like we’re connected halfway. I don’t want to learn about your worries by accident. When I talk to you about feeling isolated, you don't seem to think it’s a problem. I need to do something different.”

“Things are going to be okay,” I said. “It’s just residency.”

Were things really so bad? Neurosurgical training, among the most rigorous and demanding of all medical specialties, had surely put a strain on our marriage. There were so many nights when I came home late from work, after Lucy had gone to bed, and collapsed on the living room floor, exhausted, and so many mornings when I left for work in the early dark, before she’d awoken. But our careers were peaking now—most universities wanted both of us: me in neurosurgery, Lucy in internal medicine. We’d survived the most difficult part of our journey. Hadn’t we discussed this a dozen times? Didn’t she realize this was the worst possible time for her to blow things up? Didn’t she see that I had only one year left in residency, that I loved her, that we were so close to the life together we’d always wanted?



“If it were just residency, I could make it,” she said. “We’ve made it this far. But the problem is, what if it’s not just residency? Do you really think things will be better when you’re an academic neurosurgery attending?”

I offered to skip the trip, to be more open, to see the couples therapist Lucy had suggested a few months ago, but she insisted that she needed time—alone. At that point, the fuzziness of the confusion dissipated, leaving only a hard edge. Fine, I said. If she decided to leave, then I would assume the relationship was over. If it turned out that I had cancer, I wouldn’t tell her—she’d be free to live whatever life she chose.

Before leaving for New York, I snuck in a few medical appointments to rule out some common cancers in the young. (Testicular? No. Melanoma? No. Leukemia? No.) The neurosurgical service was busy, as always. Thursday night slipped into Friday morning as I was caught in the operating room for thirty-six hours straight, in a series of deeply complex cases: giant aneurysms, intracerebral arterial bypasses, arteriovenous malformations. I breathed a silent thanks when the attending came in, allowing me a few minutes to ease my back against a wall. The only time to get a chest X-ray was as I was leaving the hospital, on the way home before heading to the airport. I figured either I had cancer, in which case this might be the last time I would see my friends, or I didn’t, in which case there was no reason to cancel the trip.



I rushed home to grab my bags. Lucy drove me to the airport and told me she had scheduled us into couples therapy.

From the gate, I sent her a text message: “I wish you were here.”

A few minutes later, the response came back: “I love you. I will be here when you get back.”

My back stiffened terribly during the flight, and by the time I made it to Grand Central to catch a train to my friends’ place upstate, my body was rippling with pain. Over the past few months, I’d had back spasms of varying ferocity, from simple ignorable pain, to pain that made me forsake speech to grind my teeth, to pain so severe I curled up on the floor, screaming. This pain was toward the more severe end of the spectrum. I lay down on a hard bench in the waiting area, feeling my back muscles contort, breathing to control the pain—the ibuprofen wasn’t touching this—and naming each muscle as it spasmed to stave off tears: erector spinae, rhomboid, latissimus, piriformis…



A security guard approached. “Sir, you can’t lie down here.”

“I’m sorry,” I said, gasping out the words. “Bad…back…spasms.”

“You still can’t lie down here.”

I’m sorry, but I’m dying from cancer.

The words lingered on my tongue—but what if I wasn’t? Maybe this was just what people with back pain live with. I knew a lot about back pain—its anatomy, its physiology, the different words patients used to describe different kinds of pain—but I didn’t know what it felt like. Maybe that’s all this was. Maybe. Or maybe I didn’t want the jinx. Maybe I just didn’t want to say the word cancer out loud.

I pulled myself up and hobbled to the platform.

It was late afternoon when I reached the house in Cold Spring, fifty miles north of Manhattan on the Hudson River, and was greeted by a dozen of my closest friends from years past, their cheers of welcome mixed with the cacophony of young, happy children. Hugs ensued, and an ice-cold dark and stormy made its way to my hand.



“No Lucy?”

“Sudden work thing,” I said. “Very last-minute.”

“Oh, what a bummer!”

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