When Breath Becomes Air Part 4

"We can talk about therapies later," she said. "We can talk about your going back to work, too, if that's what you'd like to do. The traditional chemotherapy combination-cisplatin, pemetrexed, possibly with Avastin, too-has a high rate of peripheral neuropathy, so we'd probably switch the cisplatin for carboplatin, which will protect your nerves better, since you're a surgeon."

Go back to work? What is she talking about? Is she delusional? Or am I dead wrong about my prognosis? And how can we talk about any of this without a realistic estimate of survival? The ground, having already buckled and roiled over the past few days, did so again.

"We can do details later," she continued, "as I know this is a lot to absorb. Mostly, I just wanted to meet you all before our appointment Thursday. Is there anything I can do, or answer-besides survival curves-today?"

"No," I said, my mind reeling. "Thanks so much for stopping by. I really appreciate it."

"Here's my card," she said, "and there's the clinic number. Feel free to call if anything comes up before we see you in two days."

My family and friends quickly wired through our network of medical colleagues to find out who the best lung cancer oncologists in the country were. Houston and New York had major cancer centers; was that where I should be treated? The logistics of moving or temporarily relocating or what have you-that could be sorted out later. The replies came back quickly, and more or less unanimously: Emma not only was one of the best-a world-renowned oncologist who served as the lung cancer expert on one of the major national cancer advisory boards-but she was also known to be compa.s.sionate, someone who knew when to push and when to hold back. I briefly wondered at the string of events that had sent me looping through the world, my residency determined by a computerized match process, only to end up a.s.signed here, with a freak diagnosis, in the hands of one of the finest doctors to treat it.

Having spent the better part of the week bedridden, with the cancer progressing, I had grown noticeably weaker. My body, and the ident.i.ty tied to it, had radically changed. No longer was getting in and out of bed to go to the bathroom an automated subcortical motor program; it took effort and planning. The physical therapists left a list of items to ease my transition home: a cane, a modified toilet seat, foam blocks for leg support while resting. A bevy of new pain medications was prescribed. As I hobbled out of the hospital, I wondered how, just six days ago, I had spent nearly thirty-six straight hours in the operating room. Had I grown that much sicker in a week? Yes, in part. But I had also used a number of tricks and help from co-surgeons to get through those thirty-six hours-and, even so, I had suffered excruciating pain. 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 the 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 an invalid.

Usually when I had a patient with a strange condition, I consulted the relevant specialist and spent time reading about it. This seemed no different, but as I started reading about chemo, which included a whole variety of agents, and a raft of more modern novel treatments that targeted specific mutations, the sheer number of questions I had prevented any useful directed study. (Alexander Pope: "A little learning is a dangerous thing; / Drink deep, or taste not the Pierian spring.") Without appropriate medical experience, I couldn't place myself in this new world of information, couldn't find my spot on the Kaplan-Meier curve. I waited, expectantly, for my clinic visit.

But mostly, I rested.

I sat, staring at a photo of Lucy and me from medical school, dancing and laughing; it was so sad, those two, planning a life together, unaware, never suspecting their own fragility. My friend Laurie had had a fiance when she'd died in a car accident-was this any crueler?

My family engaged in a flurry of activity to transform my life from that of a doctor to that of a patient. We set up an account with a mail-order pharmacy, ordered a bed rail, and bought an ergonomic mattress to help alleviate the searing back pain. Our financial plan, which a few days before had banked on my income increasing sixfold in the next year, now looked precarious, and a variety of new financial instruments seemed necessary to protect Lucy. My father declared that these modifications were capitulations to the disease: I was going to beat this thing, I would somehow be cured. How often had I heard a patient's family member make similar declarations? I never knew what to say to them then, and I didn't know what to say to my father now.

What was the alternate story?

- Two days later, Lucy and I met Emma in the clinic. My parents hovered in the waiting room. The medical a.s.sistant took my vitals. Emma and her nurse pract.i.tioner were remarkably punctual, and Emma pulled up a chair in front of me, to talk face-to-face, eye-to-eye.

"h.e.l.lo again," she said. "This is Alexis, my right hand." She gestured to the NP, who sat at the computer taking notes. "I know there's a lot to discuss, but first: How are you doing?"

"Okay, all things considered," I said. "Enjoying my 'vacation,' I guess. How are you?"

"Oh, I'm okay." She paused-patients don't typically ask how their doctors are doing, but Emma was also a colleague. "I'm running the inpatient service this week, so you know how that is." She smiled. Lucy and I did know. Outpatient specialists rotated on the inpatient service periodically, adding several hours of work in an already jam-packed day.

After more pleasantries, we settled into a comfortable discussion on the state of lung cancer research. There were two paths forward, she said. The traditional method was chemotherapy, which generically targeted rapidly dividing cells-primarily cancer cells but also cells in your bone marrow, hair follicles, intestines, and so forth. Emma reviewed the data and options, lecturing as if to another doctor-but again with the exception of any mention of Kaplan-Meier survival curves. Newer therapies had been developed, however, targeting specific molecular defects in the cancer itself. I had heard rumors of such efforts-it had long been a holy grail in cancer work-and was surprised to learn how much progress had been made. These treatments, it seemed, had led to long-term survival in "some" patients.

"Most of your tests are back," Emma said. "You have a PI3K mutation, but no one's sure what that means yet. The test for the most common mutation in patients like you, EGFR, is still pending. I'm betting that's what you have, and if so, there's a pill called Tarceva that you can take instead of chemotherapy. That result should be back tomorrow, Friday, but you're sick enough that I've set you up for chemo starting Monday in case the EGFR test is negative."

I immediately felt a kinship. This was exactly how I approached neurosurgery: have a plan A, B, and C at all times.

"With chemo, our main decision will be carboplatin versus cisplatin. In isolated studies, head-to-head, carboplatin is better tolerated. Cisplatin has potentially better results but much worse toxicity, especially for the nerves, though all the data is old, and there's no direct comparison within our modern chemo regimens. Do you have any thoughts?"

"I'm less worried about protecting my hands for surgery," I said. "There's a lot I can do with my life. If I lose my hands, I can find another job, or not work, or something."

She paused. "Let me ask this: Is surgery important to you? Is it something you want to do?"

"Well, yes, I've spent almost a third of my life preparing for it."

"Okay, then I'm going to suggest we stick with the carboplatin. I don't think it will change survival, and I do think it could dramatically change your quality of life. Do you have any other questions?"

She seemed clear that this was the way to go, and I was happy to follow. Maybe, I began to let myself believe, performing surgery again was a possibility. I felt myself relax a little.

"Can I start smoking?" I joked.

Lucy laughed, and Emma rolled her eyes.

"No. Any serious questions?"

"The Kaplan-Meier-"

"We're not discussing that," she said.

I didn't understand her resistance. After all, I was a doctor familiar with these statistics. I could look them up myself...so that's what I would have to do.

"Okay," I said, "then I think everything is pretty clear. We'll hear from you tomorrow about the EGFR results. If yes, then we'll start a pill, Tarceva. If no, then we start chemotherapy Monday."

"Right. The other thing I want you to know is this: I am your doctor now. Any problem you have, from primary care to whatever, you come to us first."

Again, I felt a pang of kinship.

"Thanks," I said. "And good luck on the inpatient wards."

She left the room, only to pop her head back in a second later. "Feel free to say no to this, but there are some lung cancer fundraisers who would love to meet you. Don't answer now-think about it, and let Alexis know if you might be interested. Don't do anything you don't want to."

As we left, Lucy remarked, "She's great. She's a good fit for you. Although..." She smiled. "I think she likes you."

"And?"

"Well, there's that study that says doctors do a worse job prognosticating for patients they're personally invested in."

"On our list of things to worry about," I said, with a laugh, "I think that's in the bottom quartile."

I began to realize that coming in such close contact with my own mortality 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.

- Slowly the medical fog was clearing-at least now I had enough information to dive into the literature. While the numbers were fuzzy, having an EGFR mutation seemed to add around a year of life on average, with the potential for long-term survival; not having it suggested an 80 percent chance of death within two years. Clarifying the rest of my life was going to be a process.

The next day, Lucy and I went to the sperm bank, to preserve gametes and options. We had always planned to have kids at the end of my residency, but now...The cancer drugs would have an unknown effect on my sperm, so to keep a chance of having children, we'd have to freeze sperm before I started treatment. A young woman walked us through a variety of payment plans and options for storage and legal forms for ownership. On her desk were a mult.i.tude of colorful pamphlets about various social outings for young people with cancer: improv groups, a cappella groups, open-mike nights, and so on. I envied their happy faces, knowing that, statistically, they all probably had highly treatable forms of cancer, and reasonable life expectancies. Only 0.0012 percent of thirty-six-year-olds get lung cancer. Yes, all cancer patients are unlucky, but there's cancer, and then there's CANCER, and you have to be really unlucky to have the latter. When she asked us to specify what would happen to the sperm if one of us "were to die"-who would legally own them in the event of death-tears began rolling down Lucy's face.

The word hope first appeared in English about a thousand years ago, denoting some combination of confidence and desire. But what I desired-life-was not what I was confident about-death. When I talked about hope, then, did I really mean "Leave some room for unfounded desire?" No. Medical statistics not only describe numbers such as mean survival, they measure our confidence in our numbers, with tools like confidence levels, confidence intervals, and confidence bounds. So did I mean "Leave some room for a statistically improbable but still plausible outcome-a survival just above the measured 95 percent confidence interval?" Is that what hope was? Could we divide the curve into existential sections, from "defeated" to "pessimistic" to "realistic" to "hopeful" to "delusional"? Weren't the numbers just the numbers? Had we all just given in to the "hope" that every patient was above average?

It occurred to me that my relationship with statistics changed as soon as I became one.

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 ninety-four, in the last stages of dementia, with a severe brain bleed. But for someone like me-a thirty-six-year-old given a diagnosis of terminal cancer-there aren't really words.

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, say, or someone thinking his benign skin spots are signs of imminent death-doctors are entrusted to bring that person's expectations into the realm of reasonable possibility. 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 we arrived home from the sperm bank, 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. In the weeks that followed, my appet.i.te returned. I put on a little weight. I developed the characteristic severe acne that correlates with a good response. Lucy had always loved my smooth skin, but now it was pockmarked and, with my blood thinners, constantly bleeding. Any part of me that identified with being handsome was slowly being erased-though, in fairness, I was happy to be uglier and alive. Lucy said she loved my skin just the same, acne and all, but while I knew that our ident.i.ties derive not just from the brain, I was living its embodied nature. The man who loved hiking, camping, and running, who expressed his love through gigantic hugs, who threw his giggling niece high in the air-that was a man I no longer was. At best, I could aim to be him again.

At our first of several biweekly appointments, Emma's and my discussion tended from the medical ("How's the rash?") to the more existential. The traditional cancer narrative-that one ought to recede, spend time with family, and settle one's toes in the peat-was one option.

"Many people, once diagnosed, quit work entirely," she said. "Others focus on it heavily. Either way is okay."

"I had mapped out this whole forty-year career for myself-the first twenty as a surgeon-scientist, the last twenty as a writer. But now that I am likely well into my last twenty years, I don't know which career I should be pursuing."

"Well, I can't tell you that," she said. "I can only say that you can get back to surgery if you want, but you have to figure out what's most important to you."

"If I had some sense of how much time I have left, it'd be easier. If I had two years, I'd write. If I had ten, I'd get back to surgery and science."

"You know I can't give you a number."

Yes, I knew. It was up to me, to quote her oft-repeated refrain, to find my values. Part of me felt this was a cop-out: okay, fine, I never gave out specific numbers to patients, either, but didn't I always have a sense of how the patient would do? How else did I make life-and-death decisions? Then I recalled the times I had been wrong: the time I had counseled a family to withdraw life support for their son, only for the parents to appear two years later, showing me a YouTube video of him playing piano, and delivering cupcakes in thanks for saving his life.

My oncology appointments were the most important of many new appointments with a variety of healthcare providers, but they weren't the only ones. At Lucy's insistence, we began seeing a couples therapist who specialized in cancer patients. Sitting in her windowless office, in side-by-side armchairs, Lucy and I detailed the ways in which our lives, present and future, had been fractured by my diagnosis, and the pain of knowing and not knowing the future, the difficulty in planning, the necessity of being there for each other. In truth, cancer had helped save our marriage.

"Well, you two are coping with this better than any couple I've seen," the therapist said at the end of our first session. "I'm not sure I have any advice for you."

I laughed as we walked out-at least I was excelling at something again. The years of ministering to terminally ill patients had borne some fruit! I turned to Lucy, expecting to see a smile; instead, she was shaking her head.

"Don't you get it?" she said, taking my hand in hers. "If we're the best at this, that means it doesn't get better than this."

If the weight of mortality does not grow lighter, does it at least get more familiar?

Once I had been diagnosed with a terminal illness, I began to view the world through two perspectives; I was starting to see death as both doctor and patient. As a doctor, I knew not to declare "Cancer is a battle I'm going to win!" or ask "Why me?" (Answer: Why not me?) I knew a lot about medical care, complications, and treatment algorithms. I quickly learned from my oncologist and my own study that stage IV lung cancer today was a disease whose story might be changing, like AIDS in the late 1980s: still a rapidly fatal illness but with emerging therapies that were, for the first time, providing years of life.

While being trained as a physician and scientist had helped me process the data and accept the limits of what that data could reveal about my prognosis, it didn't help me as a patient. It didn't tell Lucy and me whether we should go ahead and have a child, or what it meant to nurture a new life while mine faded. Nor did it tell me whether to fight for my career, to reclaim the ambitions I had single-mindedly pursued for so long, but without the surety of the time to complete them.

Like my own patients, I had to face my mortality and try to understand what made my life worth living-and I needed Emma's help to do so. 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.

- The bulk of my week was spent not in cognitive therapy but in physical therapy. I had sent nearly every one of my patients to physical therapy. And now I found myself shocked at how difficult it was. As a doctor, you have a sense of what it's like to be sick, but until you've gone through it yourself, you don't really know. It's like falling in love or having a kid. You don't appreciate the mounds of paperwork that come along with it, or the little things. When you get an IV placed, for example, you can actually taste the salt when they start infusing it. They tell me that this happens to everybody, but even after eleven years in medicine, I had never known.

In physical therapy, I was not even lifting weights yet, just lifting my legs. This was exhausting and humiliating. My brain was fine, but I did not feel like myself. My body was frail and weak-the person who could run half marathons was a distant memory-and that, too, shapes your ident.i.ty. Racking back pain can mold an ident.i.ty; fatigue and nausea can, as well. Karen, my PT, asked me what my goals were. I picked two: riding my bike and going for a run. In the face of weakness, determination set in. Day after day I kept at it, and every tiny increase in strength broadened the possible worlds, the possible versions of me. I started adding reps, weights, and minutes to my workouts, pushing myself to the point of vomiting. After two months, I could sit for thirty minutes without tiring. I could start going to dinner with friends again.

One afternoon, Lucy and I drove down to Caada Road, our favorite biking spot. (Usually we would bike there, pride forces me to add, but the hills were still too formidable for my lightweight frame.) I managed six wobbly miles. It was a far cry from the breezy, thirty-mile rides of the previous summer, but at least I could balance on two wheels.

Was this a victory or a defeat?

I began to look forward to my meetings with Emma. In her office, I felt like myself, like a self. Outside her office, I no longer knew who I was. Because I wasn't working, I didn't feel like myself, a neurosurgeon, a scientist-a young man, relatively speaking, with a bright future spread before him. Debilitated, at home, I feared I wasn't much of a husband for Lucy. I had pa.s.sed from the subject to the direct object of every sentence of my life. In fourteenth-century philosophy, the word patient simply meant "the object of an action," and I felt like one. As a doctor, I was an agent, a cause; as a patient, I was merely something to which things happened. But in Emma's office, Lucy and I could joke, trade doctor lingo, talk freely about our hopes and dreams, try to a.s.semble a plan to move forward. Two months in, Emma remained vague about any prognostication, and every statistic I cited she rebuffed with a reminder to focus on my values. Though I felt dissatisfied, at least I felt like somebody, a person, rather than a thing exemplifying the second law of thermodynamics (all order tends toward entropy, decay, etc.).

Flush in the face of mortality, many decisions became compressed, urgent and unreceding. Foremost among them for us: Should Lucy and I have a child? Even if our marriage had been strained toward the end of my residency, we had always remained very much in love. Our relationship was still deep in meaning, a shared and evolving vocabulary about what mattered. If human relationality formed the bedrock of meaning, it seemed to us that rearing children added another dimension to that meaning. It had been something we'd always wanted, and we were both impelled by the instinct to do it still, to add another chair to our family's table.

Both of us yearning to be parents, we each thought of the other. Lucy hoped I had years left, but understanding my prognosis, she felt that the choice-whether to spend my remaining time as a father-should be mine.

"What are you most afraid or sad about?" she asked me one night as we were lying in bed.

"Leaving you," I told her.

I knew a child would bring joy to the whole family, and I couldn't bear to picture Lucy husbandless and childless after I died, but I was adamant that the decision ultimately be hers: she would likely have to raise the child on her own, after all, and to care for both of us as my illness progressed.

"Will having a newborn distract from the time we have together?" she asked. "Don't you think saying goodbye to your child will make your death more painful?"

"Wouldn't it be great if it did?" I said. Lucy and I both felt that life wasn't about avoiding suffering.

Years ago, it had occurred to me that Darwin and Nietzsche agreed on one thing: the defining characteristic of the organism is striving. Describing life otherwise was like painting a tiger without stripes. After so many years of living with death, I'd come to understand that the easiest death wasn't necessarily the best. We talked it over. Our families gave their blessing. We decided to have a child. We would carry on living, instead of dying.

Because of the medications I was on, a.s.sisted reproduction appeared to be the only route forward. So we visited a specialist at a reproductive endocrinology clinic in Palo Alto. She was efficient and professional, but her lack of experience dealing with terminally ill, as opposed to infertile, patients was obvious. She plowed through her spiel, eyes on her clipboard: "How long have you been trying?"

"Well, we haven't yet."

"Oh, right. Of course."

Finally she asked, "Given your, uh, situation, I a.s.sume you want to get pregnant fast?"

"Yes," Lucy said. "We'd like to start right away."

"I'd suggest you begin with IVF, then," she said.

When I mentioned that we'd rather minimize how many embryos were created and destroyed, she looked slightly confused. Most people who came here prized expedience above all. But I was determined to avoid the situation where, after I died, Lucy had responsibility for a half dozen embryos-the last remnants of our shared genomes, my last presence on this earth-stuck in a freezer somewhere, too painful to destroy, impossible to bring to full humanity: technological artifacts that no one knew how to relate to. But after several trials of intrauterine insemination, it was clear we needed a higher level of technology: we would need to create at least a few embryos in vitro and implant the healthiest. The others would die. Even in having children in this new life, death played its part.

- Six weeks after starting treatment, I was due for my first CT scan to measure the efficacy of the Tarceva. As I hopped out of the scanner, the CT tech looked at me. "Well, Doc," he offered, "I'm not supposed to say this, but there's a computer back there if you want to take a look." I loaded up the images on the viewer, typing in my own name.

The acne was a rea.s.suring sign. My strength had also improved, though I was still limited by back pain and fatigue. Sitting there, I reminded myself of what Emma had said: even a small amount of tumor growth, so long as it was small, would be considered a success. (My father, of course, had predicted that all the cancer would be gone. "Your scan will be clear, Pubby!" he'd declared, using my family nickname.) I repeated to myself that even small growth was good news, took a breath, and clicked. The images materialized on the screen. My lungs, speckled with innumerable tumors before, were clear except for a one-centimeter nodule in the right upper lobe. I could make out my spine beginning to heal. There had been a clear, dramatic reduction in tumor burden.

Relief washed over me.

My cancer was stable.

When we met Emma the next day she still refused to talk prognosis, but she said, "You're well enough that we can meet every six weeks now. Next time we meet, we can start to talk about what your life might be like." I could feel the chaos of the past months receding, a sense of a new order settling in. My contracted sense of the future began to relax.

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 merely 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, whose bodies could still tolerate standing for a grueling eight-hour surgery. 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: early career awards, promotions, new houses.

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, as Emma had implied? 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 illnesses 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. I thought back to my younger self, who might've wanted to "forge in the smithy of my soul the uncreated conscience of my race"; looking into my own soul, I found the tools too brittle, the fire too weak, to forge even my own conscience.

Lost in a featureless wasteland of my own mortality, and finding no traction in the reams of scientific studies, intracellular molecular pathways, and endless curves of survival statistics, I began reading literature again: Solzhenitsyn's Cancer Ward, B. S. Johnson's The Unfortunates, Tolstoy's Ivan Ilyich, Nagel's Mind and Cosmos, Woolf, Kafka, Montaigne, Frost, Greville, memoirs of cancer patients-anything by anyone who had ever written about mortality. I was searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again. The privilege of direct experience had led me away from literary and academic work, yet now I felt that to understand my own direct experiences, I would have to translate them back into language. Hemingway described his process in similar terms: acquiring rich experiences, then retreating to cogitate and write about them. I needed words to go forward.

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 impa.s.sable 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, its 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."

That morning, I made a decision: I would push myself to return to the OR. Why? Because I could. Because that's who I was. Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I'm dying, until I actually die, I am still living.

- Over the next six weeks, I altered my physical therapy program, focusing now on building strength specifically for operating: long hours of standing, micromanipulation of small objects, p.r.o.nation for placing pedicle screws.

Another CT scan followed. The tumor had shrunk slightly more. Going over the images with me, Emma said, "I don't know how long you've got, but I will say this: the patient I saw just before you today has been on Tarceva for seven years without a problem. You've still got a ways to go before we're that comfortable with your cancer. But, looking at you, thinking about living ten years is not crazy. You might not make it, but it's not crazy."

Here was the prognostication-no, not prognostication: justification. Justification of my decision to return to neurosurgery, to return to life. One part of me exulted at the prospect of ten years. Another part wished she'd said, "Going back to being a neurosurgeon is crazy for you-pick something easier." I was startled to realize that in spite of everything, the last few months had had one area of lightness: not having to bear the tremendous weight of the responsibility neurosurgery demanded-and part of me wanted to be excused from picking up the yoke again. Neurosurgery is really hard work, and no one would have faulted me for not going back. (People often ask if it is a calling, and my answer is always yes. You can't see it as a job, because if it's a job, it's one of the worst jobs there is.) A couple of my professors actively discouraged the idea: "Shouldn't you be spending time with your family?" ("Shouldn't you?" I wondered. I was making the decision to do this work because this work, to me, was a sacred thing.) Lucy and I had just reached the top of the hill, the landmarks of Silicon Valley, buildings bearing the names of every biomedical and technological transformation of the last generation, unfolding below us. Eventually, though, the itch to hold a surgical drill again had become too compelling. Moral duty has weight, things that have weight have gravity, and so the duty to bear mortal responsibility pulled me back into the operating room. Lucy was fully supportive.

I called up the program director to tell him I was ready to return. He was thrilled. Victoria and I talked about how best to reintroduce me and get me back up to speed. I requested that a fellow resident be available to back me up at all times in case something went awry. Furthermore, I would do only one case per day. I wouldn't manage the patients outside the OR or be on call. We'd proceed conservatively. The OR schedule came out, and I was a.s.signed to a temporal lobectomy, one of my favorite operations. Commonly, epilepsy is caused by a misfiring hippocampus, which is located deep in the temporal lobe. Removing the hippocampus can cure the epilepsy, but the operation is complex, requiring gentle dissection of the hippocampus off the pia, the delicate transparent covering of the brain, right near the brain stem.

I spent the night prior poring through surgical textbooks, reviewing the anatomy and steps of the operation. I slept restlessly, seeing the angle of the head, the saw against the skull, the way the light reflects off the pia once the temporal lobe is removed. I got out of bed and put on a shirt and tie. (I had returned all my scrubs months ago, a.s.suming I'd never need them again.) I arrived at the hospital and changed into the familiar blue garb for the first time in eighteen weeks. I chatted with the patient to make sure there were no last-minute questions, then began the process of setting up the OR. The patient was intubated, the attending and I were scrubbed and ready to begin. I picked up the scalpel and incised the skin just above the ear, proceeding slowly, trying to make sure I forgot nothing and made no mistakes. With the electrocautery, I deepened the incision to the bone, then elevated the skin flap with hooks. Everything felt familiar, muscle memory kicking in. I took the drill and made three holes in the skull. The attending squirted water to keep the drill cool as I worked. Switching to the craniotome, a sideways-cutting drill bit, I connected the holes, freeing up a large piece of bone. With a crack, I pried it off. There lay the silvery dura. Happily, I hadn't damaged it with the drill, a common beginner's mistake. I used a sharp knife to open the dura without injuring the brain. Success again. I began to relax. I tacked back the dura with small st.i.tches to keep it out of the way of the main surgery. The brain gently pulsed and glistened. The huge Sylvian veins ran across the top of the temporal lobe, pristine. The familiar peach convolutions of the brain beckoned.

Suddenly, the edges of my vision dimmed. I put down my instruments and stepped back from the table. The blackness encroached farther as a feeling of lightness overcame me.

"Sorry, sir," I told the attending, "I'm feeling a little faint. I think I need to lie down. Jack, my junior resident, will finish the case."