Foreword

It occurs to me, as I write this, that the foreword to this book might be better thought of as an afterword. Because when it comes to Paul Kalanithi, all sense of time is turned on its head. To begin with—or, maybe, to end with—I got to know Paul only after his death. (Bear with me.) I came to know him most intimately when he’d ceased to be.

I met him one memorable afternoon at Stanford in early February 2014. He’d just published an op-ed titled “How Long Have I Got Left?” in The New York Times, an essay that would elicit an overwhelming response, an outpouring from readers. In the ensuing days, it spread exponentially. (I’m an infectious diseases specialist, so please forgive me for not using the word viral as a meta­phor.) In the aftermath of that, he’d asked to come see me, to chat, to get advice about literary agents, editors, the publishing process—he had a desire to write a book, this book, the one you are now holding in your hands. I recall the sun filtering through the magnolia tree out­side my office and lighting this scene: Paul seated before me, his beautiful hands exceedingly still, his prophet’s beard full, those dark eyes taking the measure of me. In my memory, the picture has a Vermeer-like quality, a camera obscura sharpness. I remember thinking, You must remember this, because what was falling on my retina was precious. And because, in the context of Paul’s diag­nosis, I became aware of not just his mortality but my own.

We talked about a lot of things that afternoon. He was a neurosurgical chief resident. We had probably crossed paths at some point, but we hadn’t shared a pa­tient that we could recall. He told me he had been an English and biology major as an undergraduate at Stan­ford, and then stayed on for a master’s in English litera­ture. We talked about his lifelong love of writing and reading. I was struck by how easily he could have been an English professor—and, indeed, he had seemed to be headed down that path at one point in his life. But then, just like his namesake on the road to Damascus, he felt the calling. He became a physician instead, but one who always dreamed of coming back to literature in some form. A book, perhaps. One day. He thought he had time, and why not? And yet now time was the very thing he had so little of.

I remember his wry, gentle smile, a hint of mischief there, even though his face was gaunt and haggard. He’d been through the wringer with this cancer but a new biological therapy had produced a good response, allow­ing him to look ahead a bit. He said during medical school he’d assumed that he would become a psychia­trist, only to fall in love with neurosurgery. It was much more than a falling in love with the intricacies of the brain, much more than the satisfaction of training his hands to accomplish amazing feats—it was a love and empathy for those who suffered, for what they endured and what he might bring to bear. I don’t think he told me this as much as I had heard about this quality of his from students of mine who were his acolytes: his fierce belief in the moral dimension of his job. And then we talked about his dying.

After that meeting, we kept in touch by email, but never saw each other again. It was not just that I disap­peared into my own world of deadlines and responsibili­ties but also my strong sense that the burden was on me to be respectful of his time. It was up to Paul if he wanted to see me. I felt that the last thing he needed was the ob­ligation to service a new friendship. I thought about him a lot, though, and about his wife. I wanted to ask him if he was writing. Was he finding the time? For years, as a busy physician, I’d struggled to find the time to write. I wanted to tell him that a famous writer, commiserating about this eternal problem, once said to me, “If I were a neurosurgeon and I announced that I had to leave my guests to go in for an emergency craniotomy, no one would say a word. But if I said I needed to leave the guests in the living room to go upstairs to write …” I wondered if Paul would have found this funny. After all, he could actually say he was going to do a craniotomy! It was plausible! And then he could go write instead.

While Paul was writing this book, he published a short, remarkable essay in Stanford Medicine, in an issue that was devoted to the idea of time. I had an essay in the same issue, my piece juxtaposed to his, though I learned of his contribution only when the magazine was in my hands. In reading his words, I had a second, deeper glimpse of something of which there had been a hint in the New York Times essay: Paul’s writing was simply stunning. He could have been writing about anything, and it would have been just as powerful. But he wasn’t writing about anything—he was writing about time and what it meant to him now, in the context of his illness. Which made it all so incredibly poignant.

But here’s the thing I must come back to: the prose was unforgettable. Out of his pen he was spinning gold.

I reread Paul’s piece again and again, trying to under­stand what he had brought about. First, it was musical. It had echoes of Galway Kinnell, almost a prose poem. (“If one day it happens / you find yourself with someone you love / in a café at one end /of the Pont Mirabeau, at the zinc bar / where wine stands in upward opening glasses …” to quote a Kinnell line, from a poem I once heard him recite in a bookstore in Iowa City, never look­ing down at the paper.) But it also had a taste of some­thing else, something from an antique land, from a time before zinc bars. It finally came to me a few days later when I picked up his essay yet again: Paul’s writing was reminiscent of Thomas Browne’s. Browne had written Religio Medici in the prose of 1642, with all its archaic spellings and speech. As a young physician, I was ob­sessed with that book, kept at it like a farmer trying to drain a bog that his father before him had failed to drain. It was a futile task, and yet I was desperate to learn its secrets, tossing it aside in frustration, then picking it up again, unsure that it had anything for me but, in sound­ing the words, sensing that it did. I felt that I lacked some critical receptor for the letters to sing, to impart their meaning. It remained opaque, no matter how hard I tried.

Why, you ask? Why did I persevere? Who cares about Religio Medici ?

Well, my hero William Osler cared, that’s who. Osler was the father of modern medicine, a man who died in 1919. He had loved the book. He kept it on his night­stand. He’d asked to be buried with a copy of Religio Medici. For the life of me, I didn’t get what Osler saw in it. After many tries—and after some decades—the book finally revealed itself to me. (It helped that a newer edi­tion had modern spellings.) The trick, I discovered, was to read it aloud, which made the cadence inescapable: “We carry with us the wonders, we seek without us: There is all Africa, and her prodigies in us; we are that bold and adventurous piece of nature, which he that studies, wisely learns in a compendium, what others la­bour at in a divided piece and endless volume.” When you come to the last paragraph of Paul’s book, read it aloud and you will hear that same long line, the cadence you think you can tap your feet to … but as with Browne, you will be just off. Paul, it occurred to me, was Browne redux. (Or given that forward time is our illusion, per­haps it’s that Browne was Kalanithi redux. Yes, it’s head-spinning stuff.)

And then Paul died. I attended his memorial in the Stanford church, a gorgeous space where I often go when it is empty to sit and admire the light, the silence, and where I always find renewal. It was packed for the service. I sat off to one side, listening to a series of mov­ing and sometimes raucous stories from his closest friends, his pastor, and his brother. Yes, Paul was gone, but strangely, I felt I was coming to know him, beyond that visit in my office, beyond the few essays he’d writ­ten. He was taking form in those tales being told in the Stanford Memorial Church, its soaring cathedral dome a fitting space in which to remember this man whose body was now in the earth but who nevertheless was so palpa­bly alive. He took form in the shape of his lovely wife and baby daughter, his grieving parents and siblings, in the faces of the legions of friends, colleagues, and former pa­tients who filled that space; he was there at the reception later, outdoors in a setting where so many came to­gether. I saw faces looking calm, smiling, as if they had witnessed something profoundly beautiful in the church. Perhaps my face was like that, too: we had found mean­ing in the ritual of a service, in the ritual of eulogizing, in the shared tears. There was further meaning residing in this reception where we slaked our thirst, fed our bodies, and talked with complete strangers to whom we were intimately connected through Paul.

But it was only when I received the pages that you now hold in your hands, two months after Paul died, that I felt I had finally come to know him, to know him better than if I had been blessed to call him a friend. After read­ing the book you are about to read, I confess I felt inade­quate: there was an honesty, a truth in the writing that took my breath away.

Be ready. Be seated. See what courage sounds like. See how brave it is to reveal yourself in this way. But above all, see what it is to still live, to profoundly influ­ence the lives of others after you are gone, by your words. In a world of asynchronous communication, where we are so often buried in our screens, our gaze rooted to the rectangular objects buzzing in our hands, our attention consumed by ephemera, stop and experience this dia­logue with my young departed colleague, now ageless and extant in memory. Listen to Paul. In the silences be­tween his words, listen to what you have to say back. Therein lies his message. I got it. I hope you experience it, too. It is a gift. Let me not stand between you and Paul.

***

Part I

In Perfect Health I Begin

The hand of the Lord was upon me, and carried me out in the spirit of the Lord, and set me down in the midst of the valley which was full of bones,

And caused me to pass by them round about: and, behold, there were very many in the open valley; and, lo, they were very dry.

And he said unto me, Son of man, can these bones live?

—­Ezekiel 37:1–­3, King James translation

I knew with certainty that I would never be a doctor. I stretched out in the sun, relaxing on a desert plateau just above our house. My uncle, a doctor, like so many of my relatives, had asked me earlier that day what I planned on doing for a career, now that I was heading off to college, and the question barely registered. If you had forced me to answer, I suppose I would have said a writer, but frankly, thoughts of any career at this point seemed absurd. I was leaving this small Arizona town in a few weeks, and I felt less like someone preparing to climb a career ladder than a buzzing electron about to achieve escape velocity, flinging out into a strange and sparkling universe.

I lay there in the dirt, awash in sunlight and memory, feeling the shrinking size of this town of fifteen thousand, six hundred miles from my new college dormitory at Stanford and all its promise.

I knew medicine only by its absence—­specifically, the absence of a father growing up, one who went to work before dawn and returned in the dark to a plate of reheated dinner. When I was ten, my father had moved us—­three boys, ages fourteen, ten, and eight—­from Bronxville, New York, a compact, affluent suburb just north of Manhattan, to Kingman, Arizona, in a desert valley ringed by two mountain ranges, known primarily to the outside world as a place to get gas en route to somewhere else. He was drawn by the sun, by the cost of living—­how else would he pay for his sons to attend the colleges he aspired to?—­and by the opportunity to establish a regional cardiology practice of his own. His unyielding dedication to his patients soon made him a respected member of the community. When we did see him, late at night or on weekends, he was an amalgam of sweet affections and austere diktats, hugs and kisses mixed with stony pronouncements: “It’s very easy to be number one: find the guy who is number one, and score one point higher than he does.” He had reached some compromise in his mind that fatherhood could be distilled; short, concentrated (but sincere) bursts of high intensity could equal . . . whatever it was that other fathers did. All I knew was, if that was the price of medicine, it was simply too high.

From my desert plateau, I could see our house, just beyond the city limits, at the base of the Cerbat Mountains, amid red-­rock desert speckled with mesquite, tumbleweeds, and paddle-­shaped cacti. Out here, dust devils swirled up from nothing, blurring your vision, then disappeared. Spaces stretched on, then fell away into the distance. Our two dogs, Max and Nip, never grew tired of the freedom. Every day, they’d venture forth and bring home some new desert treasure: the leg of a deer, unfinished bits of jackrabbit to eat later, the sun-­bleached skull of a horse, the jawbone of a coyote.

My friends and I loved the freedom, too, and we spent our afternoons exploring, walking, scavenging for bones and rare desert creeks. Having spent my previous years in a lightly forested suburb in the Northeast, with a tree-­lined main street and a candy store, I found the wild, windy desert alien and alluring. On my first trek alone, as a ten-­year-­old, I discovered an old irrigation grate. I pried it open with my fingers, lifted it up, and there, a few inches from my face, were three white silken webs, and in each, marching along on spindled legs, was a glistening black bulbous body, bearing in its shine the dreaded blood-­red hourglass. Near to each spider a pale, pulsating sac breathed with the imminent birth of countless more black widows. Horror let the grate crash shut. I stumbled back. The horror came in a mix of “country facts” (Nothing is more deadly than the bite of the black widow spider) and the inhuman posture and the black shine and the red hourglass. I had nightmares for years.

The desert offered a pantheon of terrors: tarantulas, wolf spiders, fiddlebacks, bark scorpions, whip scorpions, centipedes, diamondbacks, sidewinders, Mojave greens. Eventually we grew familiar, even comfortable, with these creatures. For fun, when my friends and I discovered a wolf spider’s nest, we’d drop an ant onto its outer limits and watch as its entangled escape attempts sent quivers down the silk strands, into the spider’s dark central hole, anticipating that fatal moment when the spider would burst from its hollows and seize the doomed ant in its mandibles. “Country facts” became my term for the rural cousin of the urban legend. As I first learned them, country facts granted fairy powers to desert creatures, making, say, the Gila monster no less an actual monster than the Gorgon. Only after living out in the desert for a while did we realize that some country facts, like the existence of the jackalope, had been deliberately created to confuse city folk and amuse the locals. I once spent an hour convincing a group of exchange students from Berlin that, yes, there was a particular species of coyote that lived inside cacti and could leap ten yards to attack its prey (like, well, unsuspecting Germans). Yet no one precisely knew where the truth lay amid the whirling sand; for every country fact that seemed preposterous, there was one that felt solid and true. Always check your shoes for scorpions, for example, seemed plain good sense.

When I was sixteen, I was supposed to drive my younger brother, Jeevan, to school. One morning, as usual, I was running late, and as Jeevan was standing impatiently in the foyer, yelling that he didn’t want to get detention again because of my tardiness, so could I please hurry the hell up, I raced down the stairs, threw open the front door . . . and nearly stepped on a snoozing six-­foot rattlesnake. It was another country fact that if you killed a rattlesnake on your doorstep, its mate and offspring would come and make a permanent nest there, like Grendel’s mother seeking her revenge. So Jeevan and I drew straws: the lucky one grabbed a shovel, the unlucky one a pair of thick gardening gloves and a pillowcase, and through a seriocomic dance, we managed to get the snake into the pillowcase. Then, like an Olympic hammer thrower, I hurled the whole out into the desert, with plans to retrieve the pillowcase later that afternoon, so as not to get in trouble with our mother.

Of our many childhood mysteries, chief among them was not why our father decided to bring his family to the desert town of Kingman, Arizona, which we grew to cherish, but how he ever convinced my mother to join him there. They had eloped, in love, across the world, from southern India to New York City (he a Christian, she a Hindu, their marriage was condemned on both sides, and led to years of familial rifts—­my mother’s mother never acknowledged my name, Paul, instead insisting I be called by my middle name, Sudhir) to Arizona, where my mother was forced to confront an intractable mortal fear of snakes. Even the smallest, cutest, most harmless red racer would send her screaming into the house, where she’d lock the doors and arm herself with the nearest large, sharp implement—­rake, cleaver, ax.

***

In residency, there’s a saying: The days are long, but the years are short. In neurosurgical training, the day usually began a little before 6 a.m., and lasted until the operating was done, which depended, in part, on how quick you were in the OR.

A resident’s surgical skill is judged by his technique and his speed. You can’t be sloppy and you can’t be slow. From your first wound closure onward, spend too much time being precise and the scrub tech will announce, “Looks like we’ve got a plastic surgeon on our hands!” Or say: “I get your strategy — by the time you finish sewing the top half of the wound, the bottom will have healed on its own. Half the work — smart!” A chief resident will advise a junior: “Learn to be fast now — you can learn to be good later.” Everyone’s eyes are always on the clock. For the patient’s sake: How long has the patient been under anesthesia? During long procedures, nerves can get damaged, muscles can break down, even causing kidney failure. For everyone else’s sake: What time are we getting out of here tonight?

There are two strategies to cutting the time short, like the tortoise and the hare. The hare moves as fast as possible, hands a blur, instruments clattering, falling to the floor; the skin slips open like a curtain, the skull flap is on the tray before the bone dust settles. But the opening might need to be expanded a centimeter here or there because it’s not optimally placed. The tortoise proceeds deliberately, with no wasted movements, measuring twice, cutting once. No step of the operation needs revisiting; everything proceeds in orderly fashion. If the hare makes too many minor missteps and has to keep adjusting, the tortoise wins. If the tortoise spends too much time planning each step, the hare wins.

The funny thing about time in the OR, whether you frenetically race or steadily proceed, is that you have no sense of it passing. If boredom is, as Heidegger argued, the awareness of time passing, this is the opposite: The intense focus makes the arms of the clock seem arbitrarily placed. Two hours can feel like a minute. Once the final stitch is placed and the wound is dressed, normal time suddenly restarts. You can almost hear an audible whoosh. Then you start wondering: How long till the patient wakes up? How long till the next case gets started? How many patients do I need to see before then? What time will I get home tonight?

It’s not until the last case finishes that you feel the length of the day, the drag in your step. Those last few administrative tasks before leaving the hospital, however far post-meridian you stood, felt like anvils. Could they wait till tomorrow? No. A sigh, and Earth continued to rotate back toward the sun.

But the years did, as promised, fly by. Six years passed in a flash, but then, heading into chief residency, I developed a classic constellation of symptoms — weight loss, fevers, night sweats, unremitting back pain, cough — indicating a diagnosis quickly confirmed: metastatic lung cancer. The gears of time ground down. While able to limp through the end of residency on treatment, I relapsed, underwent chemo and endured a prolonged hospitalization.

I emerged from the hospital weakened, with thin limbs and thinned hair. Now unable to work, I was left at home to convalesce. Getting up from a chair or lifting a glass of water took concentration and effort. If time dilates when one moves at high speeds, does it contract when one moves barely at all? It must: The day shortened considerably. A full day’s activity might be a medical appointment, or a visit from a friend. The rest of the time was rest.

With little to distinguish one day from the next, time began to feel static. In English, we use the word time in different ways, “the time is 2:45” versus “I’m going through a tough time.” Time began to feel less like the ticking clock, and more like the state of being. Languor settled in. Focused in the OR, the position of the clock’s hands might seem arbitrary, but never meaningless. Now the time of day meant nothing, the day of the week scarcely more so.

Verb conjugation became muddled. Which was correct? “I am a neurosurgeon,” “I was a neurosurgeon,” “I had been a neurosurgeon before and will be again”? Graham Greene felt life was lived in the first 20 years and the remainder was just reflection. What tense was I living in? Had I proceeded, like a burned-out Greene character, beyond the present tense and into the past perfect? The future tense seemed vacant and, on others’ lips, jarring. I recently celebrated my 15th college reunion; it seemed rude to respond to parting promises from old friends, “We’ll see you at the 25th!” with “Probably not!”

Yet there is dynamism in our house. Our daughter was born days after I was released from the hospital. Week to week, she blossoms: a first grasp, a first smile, a first laugh. Her pediatrician regularly records her growth on charts, tick marks of her progress over time. A brightening newness surrounds her. As she sits in my lap smiling, enthralled by my tuneless singing, an incandescence lights the room.

Time for me is double-edged: Every day brings me further from the low of my last cancer relapse, but every day also brings me closer to the next cancer recurrence — and eventually, death. Perhaps later than I think, but certainly sooner than I desire. There are, I imagine, two responses to that realization. The most obvious might be an impulse to frantic activity: to “live life to its fullest,” to travel, to dine, to achieve a host of neglected ambitions. Part of the cruelty of cancer, though, is not only that it limits your time, it also limits your energy, vastly reducing the amount you can squeeze into a day. It is a tired hare who now races. But even if I had the energy, I prefer a more tortoiselike approach. I plod, I ponder, some days I simply persist.

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 the preacher of Ecclesiastes described, hold so little interest: a chasing after wind, indeed.

Yet one thing cannot be robbed of her futurity: my daughter, Cady. I hope I’ll live long enough that she has some memory of me. Words have a longevity I do not. I had thought I could leave her a series of letters — but what would they really say? I don’t know what this girl will be like when she is 15; I don’t even know if she’ll take to the nickname we’ve given her. 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 the many moments in life when 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 a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

***

I hopped out of the CT scanner, seven months 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 6 p.m. I had to go see patients, organize tomorrow’s O.R. schedule, review films, dictate my clinic notes, check on my post-ops, and so on. Around 8 p.m., I sat down in the neurosurgery office, next to a radiology viewing 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 images 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. Going back to the old images, I could make out the faintest trace of it, a ghostly harbinger now brought fully into the world.

I was neither angry nor scared. It simply was. It was a fact about the world, like the distance from the sun to the Earth. I drove home and told [my wife,] Lucy. It was a Thursday night, and we wouldn’t see [my oncologist] Emma again until Monday, but Lucy and I sat down in the living room, with our laptops, and mapped out the next steps: biopsies, tests, chemotherapy. The treatments this time around would be tougher to endure, the possibility of a long life more remote. T. S. Eliot once wrote, “But at my back in a cold blast I hear / the rattle of the bones, and chuckle spread from ear to ear.” Neurosurgery would be impossible for a couple of weeks, perhaps months, perhaps forever. But we decided that all of that could wait to be real until Monday. Today was Thursday, and I’d already made tomorrow’s O.R. assignments; I planned on having one last day as a resident.

As I stepped out of my car at the hospital, at five-twenty the next morning, I inhaled deeply, smelling the eucalyptus and … was that pine? Hadn’t noticed that before. I met the resident team, assembled for morning rounds. We reviewed overnight events, new admissions, new scans, then went to see our patients before M. & M., or morbidity and mortality conference, a regular meeting in which the neurosurgeons gathered to review mistakes that had been made and cases that had gone wrong. Afterward, I spent an extra couple of minutes with a patient, Mr. R. He had developed a rare syndrome, called Gerstmann’s, where, after I’d removed his brain tumor, he’d begun showing several specific deficits: an inability to write, to name fingers, to do arithmetic, to tell left from right. I’d seen it only once before, as a medical student, eight years ago, on one of the first patients I’d followed on the neurosurgical service. Like him, Mr. R. was euphoric—I wondered if that was part of the syndrome that no one had described before. Mr. R. was getting better, though: his speech had returned almost to normal, and his arithmetic was only slightly off. He’d likely make a full recovery.

The morning passed, and I scrubbed for my last case. Suddenly the moment felt enormous. My last time scrubbing? Perhaps this was it. I watched the suds drip off my arms, then down the drain. I entered the O.R., gowned up, and draped the patient, making sure the corners were sharp and neat. I wanted this case to be perfect. I opened the skin of his lower back. He was an elderly man whose spine had degenerated, compressing his nerve roots and causing severe pain. I pulled away the fat until the fascia appeared and I could feel the tips of his vertebrae. I opened the fascia and smoothly dissected the muscle away, until only the wide, glistening vertebrae showed up through the wound, clean and bloodless. The attending wandered in as I began to remove the lamina, the back wall of the vertebrae, whose bony overgrowths, along with ligaments beneath, were compressing the nerves.

“Looks good,” he said. “If you want to go to today’s conference, I can have the fellow come in and finish.”

My back was beginning to ache. Why hadn’t I taken an extra dose of nsaids beforehand? This case should be quick, though. I was almost there.

“Naw,” I said. “I want to finish the case.”

The attending scrubbed in, and together we completed the bony removal. He began to pick away at the ligaments, beneath which lay the dura, which contained spinal fluid and the nerve roots. The most common error at this stage is tearing a hole in the dura. I worked on the opposite side. Out of the corner of my eye, I saw near his instrument a flash of blue—the dura starting to peek through.

“Watch out!” I said, just as the mouth of his instrument bit into the dura. Clear spinal fluid began to fill the wound. I hadn’t had a leak in one of my cases in more than a year. Repairing it would take another hour.

“Get the micro set out,” I said. “We have a leak.”

By the time we finished the repair and removed the compressive soft tissue, my shoulders burned. The attending broke scrub, offered his apologies and said his thanks, and left me to close. The layers came together nicely. I began to suture the skin, using a running nylon stitch. Most surgeons used staples, but I was convinced that nylon had lower infection rates, and we would do this one, this final closure, my way. The skin came together perfectly, without tension, as if there had been no surgery at all.

Good. One good thing.

As we uncovered the patient, the scrub nurse, one with whom I hadn’t worked before, said, “You on call this weekend, Doc?”

“Nope.” And possibly never again.

“Got any more cases today?” “Nope.” And possibly never again.

“Shit, well, I guess that means this is a happy ending! Work’s done. I like happy endings, don’t you, Doc?”

“Yeah. Yeah, I like happy endings.”

I sat down by the computer to enter orders as the nurses cleaned and the anesthesiologists began to wake the patient. I had always jokingly threatened that when I was in charge, instead of the high-energy pop music everyone liked to play in the O.R., we’d listen exclusively to bossa nova. I put “Getz/Gilberto” on the radio, and the soft, sonorous sounds of a saxophone filled the room.

I left the O.R. shortly after, then gathered my things, which had accumulated over seven years of work—extra sets of clothes for the nights you don’t leave, toothbrushes, bars of soap, phone chargers, snacks, my skull model and collection of neurosurgery books, and so on.

On second thought, I left my books behind. They’d be of more use here.

On my way out to the parking lot, a fellow approached to ask me something, but his pager went off. He looked at it, waved, turned, and ran back in to the hospital—“I’ll catch you later!” he called over his shoulder. Tears welled up as I sat in the car, turned the key, and slowly pulled out into the street. I drove home, walked through the front door, hung up my white coat, and took off my I.D. badge. I pulled the battery out of my pager. I peeled off my scrubs and took a long shower.

Later that night, I called [my co-resident] Victoria and told her I wouldn’t be in on Monday, or possibly ever again, and wouldn’t be setting the O.R. schedule.

“You know, I’ve been having this recurring nightmare that this day was coming,” she said. “I don’t know how you did this for so long.”