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 reassuring 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 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, 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, pronation 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.