The Hardest Questions

I recently finished When Breath Becomes Air by Paul Kalanithi, one of the most popular and highly reviewed books of last year. It’s a first-person account of the author – a 37-year-old Stanford neurosurgical resident – and his premature death. It’s a book about death and dying, but with a twist.

For me the most interesting part of the book – and what I would argue was the real underlying theme of the book – was the tension between Kalanithi’s intense, gratification-delaying work ethic and his desire to live as well as he could in the last remaining moments of his life.

There were a few passages that stood out to me.

In the fourth year of medical school, I watched as, one by one, many of my classmates elected to specialize in less demanding areas (radiology or dermatology, for example) and applied for their residencies. Puzzled by this, I gathered data from several elite medical schools and saw that the trends were the same: by the end of medical school, most students tended to focus of “lifestyle” specialties – those with more humane hours, higher salaries, and lower pressures – the idealism of their medical school application essays tempered or lost. As graduation neared and we sat down, in a Yale tradition, to rewrite our commencement oath – a melding of words of Hippocrates, Maimonides, Osler, along with a few other great medical forefathers – several students argued the removal of language insisting that we place our patients’ interests above our own. (The rest of us didn’t allow this discussion to continue for long. The words stayed. This kind of egotism struck me as antithetical to medicine and, it should be noted, entirely reasonable. Indeed, this is how 99 percent of people select their jobs: pay, work environment, hours. But that’s the point. Putting lifestyle first is how you find a job – not a calling.)

(emphasis mine)

Not exactly your typical “gather ye rosebuds while ye may” book on death and dying.

Here’s another:

Now the time of the day means nothing, the day of the weeks scarcely more. Medical training is relentlessly future-oriented, all about delayed gratification; you’re always thinking about what you’ll be doing five years down the line. But now I don’t know what I’ll be doing five years down the line. I may be dead. I may not be. [KRM note: He died less than a year later]

One more:

Kalanithi’s Doctor: I can only say that you can get back to surgery if you want, but you have to figure out what’s important to you.

Kalanithi: If I had a sense of how much time I had 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.

Kalanithi’s Doctor: You know I can’t give you a number.

The book – and that last discussion in particular – is an intense microcosm of one of the hardest questions many of us face when deciding how to allocate our time. To what extent should we plan, save, and prepare for the future and to what extent should we emphasize living well today?

My preference is to do as much of what matters now – not to plan too far ahead. Kalanitihi chose the opposite and his choices were reflected in the quality of his career, while it lasted. Still, the tone of the book has him embracing life as well as he could for as long as he could. He and his wife chose to have a child in the year he died. And so the forward-thinking mentality still seems to have won out in him – even as he was dying with terminal cancer.

I must say that I feel a tinge of envy when I read Kalanithi’s words. I don’t regret having chosen lifestyle over career. But I also know that my career arc is probably not what it would have been had I chosen to prioritize career over lifestyle. As I meditate on what makes a life worth living, I understand that the trade-offs are real. That every time I play in the mountains I’m not working on an academic paper. That every time I walk with my dogs or meditate or write for this blog with almost no audience I am not advancing my career. That there are those who are working harder than I am and will likely be rewarded with more interesting and stimulating intellectual challenges as a result.

I have come to accept these facts.

These truths were most obvious for me when I worked at the hardest and most competitive job I ever had. There, I quickly discovered that there was an inverse relationship between the quality of my work and the quality of my life. If I showed the most prestigious partners at the firm that I was willing to sacrifice weekends, vacations, and hobbies, I could outcompete other junior attorneys and be rewarded with the most prestigious projects. But I was rarely willing to do that: I consistently chose quality of life over quality of work. And I was often outcompeted and outperformed by more eager peers.

This tension is real. Life is competitive.

It’s easy to gloss over this when writing “gather ye rosebuds while ye may,” but the battle for subsistence is never-ending, and the race to achieve true excellence at the top end of what our species can do has never been more competitive. You can search for hacks and workarounds, but as a general rule, those who work the hardest earn the greatest rewards. But still, no matter what rewards you earn, the end result is always the same.

I don’t have a glib way to summarize or resolve this dilemma, except to say that finding a balance I suspect is a life-long process, and it varies from person to person.

So yes, gather ye rosebuds while ye may. Just know that it doesn’t pay. (But that doesn’t mean you shouldn’t do it anyway.)