A doctor is diagnosed with cancer and faces the illness from the other side of his desk, as a patient. Paul Kalanithi, neurological chief resident at Stanford University, writes eloquently in the NY Times about groundlessness and ambiguity, and his futile attempt to pin down the future. In his fight for survival, he comes to some important conclusions about what it means to live in the present moment authentically.
SUNDAYREVIEW | OPINION
How Long Have I Got Left?
By PAUL KALANITHI JAN. 24, 2014
AS soon as the CT scan was done, I began reviewing the images. The diagnosis
was immediate: Masses matting the lungs and deforming the spine. Cancer. In
my neurosurgical training, I had reviewed hundreds of scans for fellow doctors to
see if surgery offered any hope. I’d scribble in the chart “Widely metastatic
disease — no role for surgery,” and move on. But this scan was different: It was
I have sat with countless patients and families to discuss grim prognoses:
It’s one of the most important jobs physicians have. It’s easier when the patient
is 94, in the last stages of dementia and has a severe brain bleed. For young
people like me — I am 36 — given a diagnosis of cancer, there aren’t many words.
My standard pieces include “it’s a marathon, not a sprint, so get your daily rest”
and “illness can drive a family apart or bring it together — be aware of each
other’s needs and find extra support.”
I learned a few basic rules. Be honest about the prognosis but always leave
some room for hope. Be vague but accurate: “days to a few weeks,” “weeks to a
few months,” “months to a few years,” “a few years to a decade or more.” We
never cite detailed statistics, and usually advise against Googling survival
numbers, assuming the average patient doesn’t possess a nuanced
understanding of statistics.
People react differently to hearing “Procedure X has a 70 percent chance of
survival” and “Procedure Y has a 30 percent chance of death.” Phrased that way,
people flock to Procedure X, even though the numbers are the same. When a
close friend developed pancreatic cancer, I became the medical maven to a group
of people who were sophisticated statisticians. I still dissuaded them from
looking up the statistics, saying five-year survival curves are at least five years
out of date. Somehow I felt that the numbers alone were too dry, or that a
physician’s daily experience with illness was needed for context. Mostly, I felt
that impulse: Keep a measure of hope.
These survival curves, called Kaplan-Meier curves, are one way we measure
progress in cancer treatment, plotting the number of patients surviving over
time. For some diseases, the line looks like an airplane gently beginning its
descent; for others, like a dive bomber. Physicians think a lot about these curves,
their shape, and what they mean. In brain-cancer research, for example, while
the numbers for average survival time haven’t changed much, there’s an
increasingly long tail on the curve, indicating a few patients are living for years.
The problem is that you can’t tell an individual patient where she is on the curve.
It’s impossible, irresponsible even, to be more precise than you can be accurate.
One would think, then, that when my oncologist sat by my bedside to meet
me, I would not immediately demand information on survival statistics. But now
that I had traversed the line from doctor to patient, I had the same yearning for
the numbers all patients ask for. I hoped she would see me as someone who both
understood statistics and the medical reality of illness, that she would give me
certainty, the straight dope. I could take it. She flatly refused: “No. Absolutely
not.” She knew very well I could — and did — look up all the research on the
topic. But lung cancer wasn’t my specialty, and she was a world expert. At each
appointment, a wrestling match began, and she always avoided being pinned
down to any sort of number.
Now, instead of wondering why some patients persist in asking statistics
questions, I began to wonder why physicians obfuscate when they have so much
knowledge and experience. Initially when I saw my CT scan, I figured I had only
a few months to live. The scan looked bad. I looked bad. I’d lost 30 pounds,
developed excruciating back pain and felt more fatigued every day. My tests
revealed severely low protein levels and low blood counts consistent with the
body overwhelmed, failing in its basic drive to sustain itself.
For a few months, I’d suspected I had cancer. I had seen a lot of young
patients with cancer. So I wasn’t taken aback. In fact, there was a certain relief.
The next steps were clear: Prepare to die. Cry. Tell my wife that she should
remarry, and refinance the mortgage. Write overdue letters to dear friends. Yes,
there were lots of things I had meant to do in life, but sometimes this happens:
Nothing could be more obvious when your day’s work includes treating head
trauma and brain cancer.
But on my first visit with my oncologist, she mentioned my going back to
work someday. Wasn’t I a ghost? No. But then how long did I have? Silence.
Of course, she could not stop my intense reading. Poring over studies, I kept
trying to find the one that would tell me when my number would be up. The large
general studies said that between 70 and 80 percent of lung cancer patients
would die within two years. They did not allow for much hope. But then again,
most of those patients were older and heavy smokers. Where was the study of
nonsmoking 36-year-old neurosurgeons? Maybe my youth and health mattered?
Or maybe my disease was found so late, had spread so far, and I was already so
far gone that I was worse off than those 65-year-old smokers.
Many friends and family members provided anecdotes along the lines of myfriend’s-
friend’s-mom’s-friend or my-uncle’s-barber’s-son’s-tennis-partner has
this same kind of lung cancer and has been living for 10 years. Initially I
wondered if all the stories referred to the same person, connected through the
proverbial six degrees. I disregarded them as wishful thinking, baseless delusion.
Eventually, though, enough of those stories seeped in through the cracks of my
And then my health began to improve, thanks to a pill that targets a specific
genetic mutation tied to my cancer. I began to walk without a cane and to say
things like, “Well, it’s pretty unlikely that I’ll be lucky enough to live for a decade,
but it’s possible.” A tiny drop of hope.
In a way, though, the certainty of death was easier than this uncertain life.
Didn’t those in purgatory prefer to go to hell, and just be done with it? Was I
supposed to be making funeral arrangements? Devoting myself to my wife, my
parents, my brothers, my friends, my adorable niece? Writing the book I had
always wanted to write? Or was I supposed to go back to negotiating my
multiyear job offers?
The path forward would seem obvious, if only I knew how many months or
years I had left. Tell me three months, I’d just spend time with family. Tell me
one year, I’d have a plan (write that book). Give me 10 years, I’d get back to
treating diseases. The pedestrian truth that you live one day at a time didn’t help:
What was I supposed to do with that day? My oncologist would say only: “I can’t
tell you a time. You’ve got to find what matters most to you.”
I began to realize that coming face to face with my own mortality, in a sense,
had changed both nothing and everything. Before my cancer was diagnosed, I
knew that someday I would die, but I didn’t know when. After the diagnosis, I
knew that someday I would die, but I didn’t know when. But now I knew it
acutely. The problem wasn’t really a scientific one. The fact of death is unsettling.
Yet there is no other way to live.
The reason doctors don’t give patients specific prognoses is not merely
because they cannot. Certainly, if a patient’s expectations are way out of the
bounds of probability — someone expecting to live to 130, or someone thinking
his benign skin spots are signs of impending death — doctors are entrusted to
bring that person’s expectations into the realm of reasonable possibility.
But the range of what is reasonably possible is just so wide. Based on today’s
therapies, I might die within two years, or I might make it to 10. If you add in the
uncertainty based on new therapies available in two or three years, that range
may be completely different. Faced with mortality, scientific knowledge can
provide only an ounce of certainty: Yes, you will die. But one wants a full pound
of certainty, and that is not on offer.
What patients seek is not scientific knowledge doctors hide, but existential
authenticity each must find on her own. Getting too deep into statistics is like
trying to quench a thirst with salty water. The angst of facing mortality has no
remedy in probability.
I remember the moment when my overwhelming uneasiness yielded. Seven
words from Samuel Beckett, a writer I’ve not even read that well, learned long
ago as an undergraduate, began to repeat in my head, and the seemingly
impassable sea of uncertainty parted: “I can’t go on. I’ll go on.” I took a step
forward, repeating the phrase over and over: “I can’t go on. I’ll go on.” And then,
at some point, I was through.
I am now almost exactly eight months from my diagnosis. My strength has
recovered substantially. In treatment, the cancer is retreating. I have gradually
returned to work. I’m knocking the dust off scientific manuscripts. I’m writing
more, seeing more, feeling more. Every morning at 5:30, as the alarm clock goes
off, and my dead body awakes, my wife asleep next to me, I think again to
myself: “I can’t go on.” And a minute later, I am in my scrubs, heading to the
operating room, alive: “I’ll go on.”
Paul Kalanithi is a chief resident in neurological surgery at Stanford University.
A version of this op-ed appears in print on January 26, 2014, on page SR9 of the New York edition with the
headline: How Long Have I Got Left?.
© 2014 The New York Times Company