Chasing Wind

It was one of those stress-free days, so I wandered off to the Lake...  Haven't been there for a long time, but it remains to be a very charming place!

Chicago, IL
May 22, 2016

The journey is the reward...

My dear little Chelle-chelle,

This may be the last time I'd allow myself to call you this way, as you are a real doctor now -:)

It's been an overwhelming couple of days... I didn't anticipate the level of loud and silent celebrations -- from the ceremony itself and then via social media.  It's been a rewarding experience for me, and I am so happy for you.

Once again, Chelle, congratulations!  It's a great accomplishment, and we are all very proud of you!!

Here is a photo I put together to remind you of the young and hopeful little Michelle; to remind you of your eager and happy self when started this long journey to pursue medicine.  Now, you've been through part of the journey.  I hope your eagerness remains and your passion and devotion fresh...  From this point on, finally, grades are no longer enough.  You will soon be responsible for making life-and-death decisions, and that's an enormous thing!

I just witnessed some 180 students graduating from the same class of a medical school.  Their paths will diverge, eventually, and the road to be the BEST doctor is not easily traveled.  Continue your life-long journey with optimism, persistence, passion, devotion and strength.  I hope that at the end of the journey, you'll be able to look back and smile.

Love,

Mom  

Michelle: August 7, 2012 and May 12, 2016

Dr. Michelle

Dear Dr. Michelle,

Congratulations again -- we are very proud of you!! Continue to devote your heart and soul to what you love to do and be the best doctor you can be!

As you open a new chapter in pursuing medicine, please allow me to once again share with you a few words from the book so brilliantly written by Dr. Paul Kalanithi.

When Breath Becomes Air
By Paul Kalanithi

A life spent in medicine would grant me not merely a stage for compassionate action but an elevation of my own being: getting far away from petty materialism, from self-importance trivia, getting right there, to the heart of the matter, to truly life-and-death decisions and struggles.

A mother came to me, newly diagnosed with brain cancer. She was confused, scared, overcome by uncertainty. I was exhausted, disconnected. I rushed through her questions, assured her that surgery would be a success, and assured myself that there wasn't enough time to answer her questions fairly. But why didn't I make the time? I feared I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient. Technical excellence was not enough. As a resident, my highest ideal was not saving lives -- everyone dies eventually -- but guiding a patient or family to an understanding of illness or death.

With my renewed focus, informed consent became not a juridical exercise in naming all the risks as quickly as possible, but an opportunity to forge a covenant with a suffering compatriot: Here we are together, and here are the ways through -- I promise to guide you, as best as I can, to the other side.

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.

Remembering My Mother

Happy Mother's Day!!

I can't think of a better way to remember my Mother than paying a special tribute to her on Mother's Day.  Mom passed away 5 years ago, and I wrote this letter to her 2 weeks after her passing.   She was such a wonderful mom and a great friend...

3/5/2011:

Dear Mom,

I have not written a letter to you in such a long time.  We were so used to talking on the phone every week when I told you everything about Michelle, about my family, myself, my job and my love in photography.

 

It’s been two weeks since I talked to the doctor who treated you at the ICU.  He told me that you suffered a brain-stem hemorrhage, a condition with an extremely low survival rate.  I was in absolute disbelieve, and still am…

I remember when I was little, each night before I went to bed, I would always say: “Bye-bye, Mama, travel safe and come home early (妈妈再见, 一路平安，早点回来).”  You would smile back and then kiss my little forehead – it was so sweet and satisfying…  I remember the summer days when all the other kids were playing outside, Tang Ming and I would wash our balcony with water and wait for you to come home to have special dinners with us.  After dinner, we would lay down on our balcony and play games – that’s when I learned the word “fun.” I remember how happy I was to wait for you at the balcony each afternoon.  Once I see you walking home from far away, I would call you with my loudest voice, then rush downstairs, run to the street and run to you… I remember the night before each holiday, after going to bed, I would call you and remind you to wash my “little red guard” symbol for me to wear the next day – I always fell asleep quickly after you reassured me that everything would be in good order for “tomorrow.”  Mom, today, I want to tell you that it is the love and reassurance you have given me throughout the years that makes me so strong and confident.

I still remember vividly that when I was in first grade, you told me to study hard and go to college when I grow up.  I did not even know what “college” meant at the time, but you told me to just remember that “I need to go to college.”  I memorized it at age 6.  When my classmate’s parents asked me what I would do when I grew up, I said “I need to go to college.”  They were terrified, because during the Cultural Revolution, no one was allowed to think about going to college or pursuing academics.  They told me to never repeat what I said again.  I nodded, but deep in my heart, I knew “I need to go to college.”

Right after the Cultural Revolution, you taught me the importance of learning English.  I was skeptical and did not see the need for a proud Chinese to learn any language other than Chinese. I clearly remember what you said – foreign language is the tool for you to open the window to the foreign world.  After 33 years, today, I am still humbled by your wisdom.

      

Looking back, it’s been 23 years since I came to this foreign land.  I have shared with you every little progress I made over the years.  Mom, as I think back, I know deeply that I would not have been who I am today without your tremendous sacrifice. Please know that I understand the painful price you’ve paid for us to have a better life.  I will forever be thankful for that!

Mom, you left me so suddenly that I did not even have a chance to tell you everything I wanted to tell you –

Thank you for showing me what love really is.  Thank you for helping me see beauty and sunshine in life.  Thank you for teaching me the meaning of kindness, tolerance, optimism, persistence and strength.  Thank you for always keeping an open mind and a young heart – it’s comforting to remember that you never lost interest in exploring new things in life, even at age 85.  You enjoyed your life fully and had accomplished everything you wanted to accomplish.

 

I love you, Mom, as always.  妈妈再见, 一路平安.

Your Little Tang Pei (你的小汤培)

  

4/3/2011:

Celebrating Life

My friends told me that on the 40th day after the person's passing, there should be a celebration of that person's life.  It's been 40 days since Mom passed away on 2/22/11 at 9:42 PM.  Looking back, Mom lived a long, fulfilled and enjoyable life:

1.  She was a wonderful Mother and a loving Grandma.

2.  She was an accomplished doctor and was deeply loved and respected by her patients and colleagues.

3.  Throughout all my life, no matter when and where, she never failed to give me guidance and advice.  She was a wise lady and a great friend.

4.  She made significant sacrifice for me to have a successful life in a foreign country.

5.  She was very progressive, and I believe that her open mind, optimism, curiosity and persistence had brought her all the success in life.

6.  She loved life and truly understood how to enjoy it fully.  She had brought so much joy to her family and friends. 

Mom will always be loved and missed.

Remembering My Father

I wrote this letter to my father last April (4/12/2015 to be exact).  He read it 3 times, and his mind was very clear at the time.  Thinking back, I am glad I did it.

Dear Dad,

I meant to write this letter to you some time much later... However, as I reflect deeper on life, I've decided to write it today so you can read it when I am back to China.  I want you to read this letter while your mind is still sharp, because I want you to know how much I love you and how much I appreciate everything you've done for me. 

Like most of the typical fathers in China in the 1970s, you were not deeply involved in my day-to-day life.  However, I vividly remember a few things from my childhood:

1.  Since I was very little, you had been very strict about how I should hold chopsticks properly.  I remember that, for a period of time, at the dinner table, you would correct my way of holding chopsticks each and every time I did it wrong.  You may not remember it now, but it's amazing how small things like this could make its way to my deepest memories.

2.  Throughout my childhood, I learned first-hand how much you loved photography.  Every winter, whenever there was a snowstorm, you'd take me to Tao Ran Ting Park and take all kinds of pictures of me in the snow.  You often put me on the frozen lake, under the bridge, and took pictures at the most risky spots.  It might never have occurred to you that I could fall into one of those ice holes.  I can't tell you how many weekends we stayed in that small room with dim red light to develop our black and white pictures -- from getting the negatives to developing the paper pictures to putting the pictures on a little machine to make them glossy.  Even to this day, I still remember the smell of the chemicals for developing pictures... Because of your love for photography, I ended up with so many more childhood pictures than any of my friends, and I have always been very proud of that!

3.  Summer memories always lead me to the unforgettable swimming lessons.  We always went to the little muddy pond either at Tao Ran Ting or Shi Sha Hai, and I received my first swimming lesson from you when I was about 3 years old.  It was scary as hell, but because you loved swimming so much, you definitely wanted to be sure we'd all love swimming...  Those swimming sessions are as memorable as sitting in the small red room to develop our pictures.

4.  When I was about 10-11, I got sick very often and couldn't go to school, so you ended up spending a lot of time with me at home during that time.  I remember you tried very hard to read those famous Chinese novels to me -- Water Margin and Romances of the Three Kingdoms.  I was not particularly interested in those stories.  But for some reason, you felt it was very valuable for me to know them...

5.  In my memory, you were such a great cook. Among other delicious foods you made for us all the time, you made sure that every Chinese New Year's Eve (especially the dinner) was important and special for us.  So, Tang Ming and I would go downstairs to play with our friends from the afternoon into early evening.  Then we must come home on time for the special dinner.  You'd always cook special dishes for us that night -- the traditional southern Chinese foods, and you made sure we had fish at each Chinese New Year's Eve dinner.  This tradition lasted for many, many years.  After dinner, you'd turn on a high power light bulb and take pictures of us inside the house.  I was always fascinated by the fact that you could take such sharp pictures at night... I learned then how important a high power light bulb is for producing high quality pictures.

6.  The night photo session during the National Day holiday was another one of our family traditions.  During the National Day holiday, when all the lights were lit up on Tian An Men square, you'd take us there, by bike or by bus, to take pictures.  I was always scared of the crowds, but you reassured me that everything would be fine. During each shot, I must stand still (without any slight move) in order for you to take sharp pictures...

7.  As I grew older, you taught me one valuable lesson -- whenever possible, travel around to see the outside world.  You told me this at the end of my high school years, and it had such a profound impact on my life even to this day.  I also made sure to take my little Michelle everywhere as she grew up so she also got to see the "outside world."

8.  Although you were not very much involved in my daily life when I was little, you got more involved when I got into high school.  You did not want me to waste time on doing any housework.  The only thing you wanted me to do was to study.  You'd carefully prepare every breakfast for me on school days.  You wanted to make sure that I ate well every morning before going to school.  During my college years, every weekend when I came home, you'd cook my favorite special foods, then cook more for me to take back to school for my friends.

Looking back, I have been in America for 27 years.  Dad, I know clearly that, over all these years, you have sacrificed tremendously to support me and my family to have a successful life in this foreign country.  I would not have been who I am today without all the efforts you've made to help me in every possible way you can.  I truly understand the painful price you’ve paid for us to have a better life.  I will forever be thankful for that!

I will never forget all the attention you've given to Michelle for the past 25 years -- you carefully planned many of her birthday parties, you took so many wonderful pictures of her so we could all keep the sweet memories of baby Michelle, you carefully labeled all her favorite toys and dated all her pictures...  For the 2 years when she was in China, you kept a detailed notebook on all the important things she did every day.  One year, on her birthday, you bought a little cup for her.  On the cup, there is a blue sheep, a yellow cow, a red pig and two pieces of puffy clouds...  She loved it very much and still does after all these many years.  When she went to college, I told her the little cup must safely stay at home -- she agreed.  Even to this day, it is still sitting on her bedroom dresser.  Michelle knows clearly how much you love her, and she loves you dearly as well.  You've had a big influence on her young life, and she will forever carry the memories of the wonderful time she spent with you and Grandma during her childhood years. 

In recent years, I have been thinking more about the definition of a "successful life."  One day, in our old age, we'd all look back on life and ask ourselves -- have I lived a fulfilled life?  What is a "fulfilled and successful" life?  To answer that question, I would search my heart and soul to see if I've made an impact on the lives of people I love.  In your case, yes, you did make a significant impact on our lives, and you've left a great legacy.  That's the most important thing for you to remember and be proud of.

Thank you for everything you've done for me, Dad.  I love you, and always will.

Tang Pei

 

Starry Night

I still remember the cold morning when I went out in the dark to shoot stars.  It was back in November 2012 at Zion -- deadly quiet, deadly dark and freezing cold...  I took the shot (Picture 1 below) and was so happy about it.

It's been almost 4 years since that cold morning.  I am still pretty diligent about photography, even though I haven't made great progress compared to many of my friends.  To me, photography is just a tool for us to experience life at a deeper level.  It's also one of the best ways to channel the tremendous stress I get from work!

While traveling for work last week, I went to Redstone near Vegas to capture the true beauty of a starry night.  I am glad to see that my photography skill has improved slightly from 4 years ago... haha!!

Picture 1 = 11/2012 in Zion

Pictures 2 and 3 = 4/2016 at Redstone, Nevada

 

 

When Breath Becomes Air

When Breath Becomes Air

By Paul Kalanithi

Paul Kalanithi was a neurosurgeon and writer.  He grew up in Kingman, Arizona, and graduated from Stanford University with a BA and MA in English literature and a BA in Human Biology.  He earned an MPhil in history and philosophy of science and medicine from University of Cambridge and graduated cum laude from the Yale School of Medicine, where he was inducted into the Alpha Omega Alpha national medical honor society.  He returned to Stanford to complete his residency training in neurological surgery and postdoctoral fellowship in nueroscience, during which he received the American Academy of Neurological Surgery's highest award for research.  He died from lung cancer in March 2015 at age 36. 

.....

A few years later, I hadn't thought much more about a career but had nearly completed degrees in English literature and human biology.  I was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful?  I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain. 

Throughout college, my monastic, scholarly study of human meaning would conflict with my urge to forge and strengthen the human relationships that formed that meaning.  If the unexamined life was not worth living, was the unlived life worth examining? 

.....

Returning to the ward, I ran into Melissa.  "Hey, do you know how last night's twin babies are doing?" I asked.

She darkened.  Baby A died yesterday afternoon; Baby B managed to live not quite 24 hours, then passed away this morning...  What possible sense could be made, what words were there for comfort? 

"Was it the right choice to do an emergency C-section?" I asked.  "No question," she said. "It was the only shot they had."  "What happens if you don't?"  "Probably, they die.  Abnormal fetal heart tracings show when the fetal blood turning acidemic, the cord is compromised somehow." 

"But how do you know when the tracing looks bad enough?  Which is worse, being born too early or waiting too long to deliver?"

"Judgment call."

What a call to make.  In my life, had I ever made a decision harder than choosing between a French dip and a Reuben?  How could I ever learn to make, and live with, such a judgment call?  I still have a lot of practical medicine to learn, but would knowledge alone be enough, with life and death hanging in the balance?  Surely intelligence wasn't enough; moral clarity was needed as well.  Somehow, I had to believe, I would gain not only knowledge but wisdom, too.    

While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of ourselves, and every conversation with a patient undergoing brain surgery cannot help but confront this fact.  In addition, to the patient and family, the brain surgery is usually the most dramatic event they have ever faced and, as such, has the impact of any major life event.  At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living.  Would you trade your ability to talk for a few extra months of mute life?  The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage?  Your right hand's function to stop seizures?  How much neurologic suffering would you let your child endure before saying that death is preferable?  Because the brain mediates our experience of the world, any neurological problem forces a patient and family, ideally with a doctor as a guide, to answer this question:  What makes life meaningful enough to go on living?

I had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking.  Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining of life and death.  I had thought that a life spent in the space between the two would grant me not merely a stage for compassionate action but an elevation of my own being: getting far away from petty materialism, from self-importance trivia, getting right there, to the heart of the matter, to truly life-and-death decisions and struggles.

But in residency, something else was gradually unfolding.  In the midst of this endless barrage of head injuries, I observed a lot of suffering; worse, I became inured to it.  Drowning, even in blood, one adapts, learns to float, to swim, even to enjoy life...

One day, I heard that Laurie, a friend from medical school, had been hit by a car and that a neurosurgeon had performed an operation to try to save her.  She'd coded, was revived, and then died the following day...  I didn't want to know more.  I didn't ask for details.  I already had too many...  I feared I was on the way to becoming Tolstory's stereotype of a doctor, preoccupied with empty formalism, focused on the rote treatment of disease -- and utterly missing the larger human significance. 

A mother came to me, newly diagnosed with brain cancer.  She was confused, scared, overcome by uncertainty.  I was exhausted, disconnected.  I rushed through her questions, assured her that surgery would be a success, and assured myself that there wasn't enough time to answer her questions fairly.  But why didn't I make the time?  I feared I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient.  Technical excellence was not enough.  As a resident, my highest ideal was not saving lives -- everyone dies eventually -- but guiding a patient or family to an understanding of illness or death.    

With my renewed focus, informed consent -- the ritual by which a patient signs a piece of paper, authorizing surgery -- became not a juridical exercise in naming all the risks as quickly as possible, but an opportunity to forge a covenant with a suffering compatriot: Here we are together, and here are the ways through -- I promise to guide you, as best as I can, to the other side.

.....

  

Removing the tumor was satisfying -- even though I knew that microscopic cancer cells had already spread throughout that healthy-looking brain.  The nearly inevitable recurrence was a problem for another day.  One spoonful at a time.  Openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.

Driving home later that night, after gently explaining to a mother that her newborn had been born without a brain and would die shortly, I switched on the radio; NPR was reporting on the continuing drought in California.  Suddenly, tears were streaming down my face.  Being with patients in these moments certainly had its emotional cost, but it also had its rewards.  I don't think I ever spent a minute of any day wondering why I did this work, or whether it was worth it.  The call to protect life -- and not merely life but another's identity -- was obvious in its sacredness. 

Before operating on a patient's brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end.  The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt.  Those burdens are what make medicine holy and wholly impossible.

It felt to me as if the individual strands of biology, mortality, life and death were finally beginning to weave themselves into, if not a perfect moral system, a coherent worldview and a sense of my place in it.  Doctors in highly charged fields met patients at inflected moments, the most authentic moments, where life and identity were under threat; their duty included learning what made that particular patient's life worth living, and planning to save those things if possible -- or to allow the peace of death if not.  Such power required deep responsibility, sharing in guilt and recrimination.

I was at a conference in San Diego when my phone rang.  My co-resident, Victoria. 

"Paul?"  Something was wrong, my stomach tightened.  "What's up?" I said.  "It's Jeff.  He killed himself."  "What?"  "He, uh - he apparently had a difficult complication, and his patient died.  Last night he climbed onto the roof of a building and jumped off..."

I searched for a question to bring understanding.  None was forthcoming.  I could only imagine the overwhelming guilt, like a tidal wave, that had lifted him up and off that building.

I wished, desperately, that I could've been walking with him out of the door of the hospital that evening.  I wished we could've commiserated as we used to.  I wished I could have told Jeff what I had come to understand about life, and our chosen way of life, if only to hear his wise, clever counsel.  Death comes for all of us.  For us, for our patients.  Most lives are lived with passivity toward death -- it's something that happens to you and those around you.  But Jeff and I had trained for years to actively engaged with death, to grapple with it, and, in doing so, to confront the meaning of a life.  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.

.....

One chapter of my life seemed to have ended; perhaps the whole book is closing.  Instead of being the pastoral, figure aiding a life transition, I found myself the sheep, lost and confused.  Severe illness wasn't life-altering, it was life-shattering.  It felt less like an epiphany -- a piercing burst of light, illuminating What Really Matters -- and more like someone had just firebombed the path forward.  Now I would have to work around it.

My brother Jeevan had arrived at my bedside.  "You've accomplished so much," he said.  "You know that, don't you?"

I sighed.  He meant well, but the words rang hollow.  My life had been building potential, potential that would now go unrealized.  I had planned to do so much, and I had come so close.  I was physically debilitated, my imagined future and my personal identity collapsed, and I faced the same existential quandaries my patients faced.  The lung cancer diagnosis was confirmed.  My carefully planned and hard-won future no longer exist.  Death, so familiar to me in my work, was now paying a personal visit.  Here we are, finally face-to-face, and yet nothing about it seemed recognizable.  Standing at the crossroads where I should have been able to see and follow the footprints of the countless patients I had treated over the years, I saw instead only a blank, a harsh, vacant, gleaming white desert, as if a sandstorm had erased all trace of familiarity.

Had the confirmation of my fears -- in the CT scan, in the lab results, both showing not merely cancer but a body overwhelmed, nearing death -- released me from the duty to serve, from my duty to patients, to neurosurgery, to pursuit of goodness?  Yes, I thought, and therein was the paradox: like a runner crossing the finish line only to collapse, without that duty to care for the ill pushing me forward, I became invalid.

During my residency, I had sat with countless patients and families to discuss grim prognoses; it's one of the most important jobs you have, as a physician.  It's easier when the patient is 94, in the last stages of dementia, with a severe brain bleed.  But for someone like me -- a 36-year-old given a diagnosis of terminal cancer -- there aren't really words.

The reason doctors don't give patient specific prognoses is not merely because they cannot.  What patients seek is not scientific knowledge that doctors hide but existential authenticity each person must find on her own.  Getting too deeply into statistics is like trying to quench a thirst with salty water.  The angst of facing mortality has no remedy in probability.

When I arrived home, I got a phone call saying that I did, in fact, have a treatable mutation (EGFR).  Chemo was off, thankfully, and Tarceva, a little white pill, became my treatment.  I soon began to feel stronger.  And even though I no longer really knew what it was, I felt it: a drop of hope.  The fog surrounding my life rolled back another inch, and a sliver of blue sky peeked through...

Like my own patients, I had to face my mortality and try to understand what made my life worth living.  Torn between being a doctor and being a patient, delving into medical science and turning back to literature for answers, I struggled, while facing my own death, to rebuild my old life -- or perhaps find a new one.

.....

A local meeting of former Stanford neurosurgery graduates was happening that weekend, and I looked forward to the chance to reconnect with my former self.  Yet being there heightened the surreal contrast of what my life was now.  I was surrounded by success and possibility and ambition, by peers and seniors whose lives were running along a trajectory that was no longer mine.  I felt trapped inside a reversed Christmas carol: Victoria was opening the happy present -- grants, job offers, publications -- I should be sharing.  My senior peers were living the future that was no longer mine...

No one asked about my plans, which was a relief, since I had none.  While I could now walk without a cane, a paralytic uncertainty loomed: Who would I be, going forward, and for how long?  Invalid, scientist, teacher?  Bioethicist?  Neurosurgeon once again?  Stay-at-home dad?  Writer?  Who could or should I be?  As a doctor, I had had some sense of what patients with life-changing illness faced -- and it was exactly these moments I had wanted to explore with them.  Shouldn't terminal illness, then, be the perfect gift to that young man who had wanted to understand death?  What better way to understand it than to live it?  But I'd had no idea how hard it would be, how much terrain I would have to explore, map, settle.  I'd always imagined the doctor's work as something like connecting two pieces of railroad track, allowing a smooth journey for the patient.  I hadn't expected the prospect of facing my own mortality to be so disorienting, so dislocating. 

And so it was literature that brought me back to life during this time.  The monolithic uncertainty of my future was deadening; everywhere I turned, the shadow of death obscured the meaning of any action.  I remember the moment when my overwhelming unease yielded, when that seemingly impassable sea of uncertainty parted.  I woke up in pain, facing another day -- no project beyond breakfast seemed tenable.  I can't go on, I thought, and immediately, the antiphon responded, completing Samuel Beckett's seven words, words I had learned long ago as an undergraduate: I'll go on.  I got out of bed and took a step forward, repeating the phrase over and over: "I can't go on.  I'll go on."     

The tricky part of illness is that, as you go through it, your values are constantly changing.  You try to figure out what matters to you, and then you keep figuring it out.  It felt like someone had taken away my credit card and I was having to learn how to budget.  You may decide you want to spend your time working as a neurosurgeon, but two months later, you may feel differently.  Two months after that, you may want to learn to play the saxophone or devote yourself to church.  Death may be a one-time event, but living with terminal illness is a process.

And now, finally, maybe I had arrived at denial.  Maybe total denial.  Maybe, in the absence of any certainty, we should just assume that we're going to live a long time.  Maybe that's the only way forward.

If no longer sought to fly the highest trajectory of neurosurgeon and neuroscientist, what did I want?

To be a father?

To be a neurosurgeon?

To teach?

  

I didn't know.  But if I didn't know what I wanted, I had learned something, something not found in Hippocrates, Maimonide, or Osler: the physician's duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.

.....

I hopped out of the CT scanner, seven month since I had returned to surgery.  This would be my last scan before finishing residency, before becoming a father, before my future became real.

"Wanna take a look, Doc?" the tech said.

"Not right now," I said.  "I've got a lot of work to do today."

It was already 6pm.  I had to go to see patients, organize tomorrow's OR schedule, review films, dictate my clinic notes, check on my post-ops, and so on.  Around 8pm, I sat down in the neurosurgery office, next to a radiology reviewing station.  I turned it on, looked at my patients' scans for the next day -- two simple spine cases -- and, finally, typed in my own name.  I zipped through the image as if they were a kid's flip-book, comparing the new scan to the last.  Everything looked the same, the old tumors remained exactly the same... except, wait.

I rolled back the images.  Looked again.

There it was.  A new tumor, large, filling my right middle lobe.  It looked, oddly, like a full moon having almost cleared the horizon...  I was neither angry nor scared.  It simply was.  It was the fact about the world, like the distance between the sun to the earth.  The treatments this time around would be tougher to endure, the possibility of a long life more remote...

Everyone succumbs to finitude.  I suspect I am not the only one who reaches this pluperfect state.  Most ambitions are either achieved or abandoned; either way, they belong to the past.  The future, instead of the ladder toward the goals of life, flattens out into a perpetual present.  Money, status, all the vanities hold so little interest: a chasing after wind, indeed.

Yet, one thing cannot be robbed of her futurity: our daughter, Cady.  I hope I'll live long enough that she has some memory of me.  Words have a longevity I do not.  There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past.

That message is simple:

When you come to one of 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 sated joy, a joy unknown to me in all my prior years, a joy does not hunger for more and more but rests, satisfied.  In this time, right now, that is an enormous thing.