When the CT scan was completed, I immediately started looking at the films. The diagnosis came out immediately: large masses in both lungs and spinal deformities. Cancer. Throughout my neurosurgical career, I’ve consulted thousands of films with fellow physicians to see if surgery could offer hope. I would write a few quick notes in the chart: extensive metastasis – no indication for surgery. Then I would move on to other things. Only, this one was different: it was my own CT scan. I’ve sat down with countless patients and their families to discuss their grim outlook: this is one of the most important jobs a doctor has to do. If the patient is 94 years old, suffering from end-stage amnesia and a severe brain hemorrhage, it’s easier to talk. But for a young person like me – I’m 36 and diagnosed with cancer – there’s not much left to say. My standard sayings include, “It’s a marathon, not a sprint, so you have to rest every day,” and “Illness can tear a family apart or bring everyone together – you have to understand the needs of those around you and seek outside support. needs, and seek outside support.” I learned a few basic rules. You need to be honest when talking about the prognosis of your condition, but leave room for hope. Be both vague and precise: “from days to weeks,” “from weeks to months,” “from months to years,” “from years to decade or more”. We never cite specific data and usually advise patients and families not to search the Internet for survival figures because we suspect that the average patient will not be able to understand the data in any detail. There is a difference in reaction to hearing “70% survival rate for treatment X” and “30% mortality rate for treatment Y”. Hearing such a statement, people flock to X therapy, even though the actual results of the two therapies are the same. A close friend of mine had pancreatic cancer, and I ended up being the medical advisor to his family and friends, even though they were all very senior statisticians. I still advised them not to look for data, telling them that the five-year survival curves they could find now were at least five years behind. Somehow, I always felt that the numbers alone were too dry, or that doctors needed more context in their daily dealings with disease. More importantly, I have this urge to keep hope alive. These survival curves are called Kaplan-Meier curves, by which we can understand the progress of cancer treatment and predict how long patients will survive. For some diseases, this curve looks like a plane landing slowly; for others, it looks like a diving bomber. Doctors give a lot of thought to these curves, their shape and their meaning. In the brain cancer study, for example, although the average survival numbers didn’t change very much, the curve trailed longer and longer, meaning that some patients had survived for years. The problem is that you can’t tell where a patient is on the graph. It’s impossible, even irresponsible, to strive for data accuracy. You might think that when my oncologist sat down to meet with me at my bedside, I wouldn’t immediately ask her to tell me the data about survival. But now that I’ve slipped from the doctor’s role to the patient’s end of the spectrum, I, like all patients, am eager to know the exact numbers. I hope she recognizes that I know the data as well as the medical facts about the disease, so she should be able to provide me with accurate, straightforward conclusions. I could take it. She simply refused, “No, absolutely not.” She knew I would look up all the research on the disease – and I did. But lung cancer was not my specialty, and she was an international authority in the field. At every visit, we had a wrestling match, and she always dodged and didn’t mention any of the numbers. Now, instead of being baffled by some patients’ insistence on asking for numbers, I began to wonder why doctors had to cloud the issue so much when they had so much knowledge and so much experience. When I first saw my CT films, I thought I only had a few months to live. The films looked terrible. I looked awful. I lost 30 pounds, developed severe back pain, and felt weaker by the day. My blood work showed extremely low protein levels and a low red blood cell count, which was the same as how my body felt: it was no longer meeting the basic drive to survive. For months, I had suspected that I had cancer, and I had seen many young cancer patients, so I wasn’t surprised to learn the results. In fact, I felt a little relieved. The next thing to do was obvious: prepare to die. Cry a lot. Tell my wife she should remarry and raise money for the mortgage. Write a late letter to a good friend. Yes, I wanted to do a lot of things in this life, but sometimes these things just happen: when your day job is treating patients with severe head injuries and brain cancer, it’s obvious to you what the end is. But in my first meeting with my oncologist, she talked about the day when I would return to work. Would I be a wandering soul then? No. But how long will I have? Silence. Of course, she couldn’t stop me from reading a lot of literature. When looking for information, I always wanted to find a report that would give me an accurate figure. Numerous studies showed that 70-80% of lung cancer patients would die within two years. This didn’t give me much hope. But then again, most of the patients are much older and smoke heavily. Is there a study of a 36-year-old neurosurgeon who is a non-smoker? I’m young and in good health, so maybe that will help? Or maybe, because my disease was discovered so late and spread so far, my situation is far worse than those 65 year old smokers? Many of my friends and family have told me stories, such as a friend of a friend’s mother’s friend or an uncle’s barber’s son’s tennis partner who had the same lung cancer as I did and has now lived for 10 years. At first, I wondered if these stories were about the same person, connected by the well-known theory of six degrees of separation. I thought these stories were nothing more than wishful thinking, unfounded fantasies. But eventually, the stories drifted into the cracks of my well-versed realism. Then my health slowly began to improve, thanks to a targeted drug that targeted a specific genetic mutation related to my cancer. I could walk without crutches and say things like, “Well, I’ll be lucky to live 10 years, which is really unlikely for me, but it’s not entirely hopeful.” A tiny bit of hope. In one way, though, the certainty of death is simpler than this uncertainty of life. Wouldn’t those souls in purgatory rather hurry to hell so they could end it all? Shouldn’t I make funeral arrangements? Shouldn’t I spend all my time with my wife, parents, brothers, friends, and my sweet little niece? Write the book I’ve been wanting to write for a long time? Or should I go back to the hospital and negotiate a contract with my boss for the next two years? If I knew whether months or years awaited me, the road ahead might be much clearer. Say I had three months to go, and I would be there for my family. Say I had a year to go, and I could make a plan (to finish that book). Say I have 10 years left, and I can go back to the hospital and save lives. The old “live in the moment” rhetoric doesn’t make much sense: what should I do with the moment? My oncologist simply said, “I can’t give you a specific time. You need to discover what’s most important to you.” I began to realize that meeting my own death in a narrow way changed everything and nothing at the same time. Before the cancer diagnosis, I knew I would die someday, but I didn’t know when that would be. After the diagnosis, I knew I would die someday, but I still didn’t know when. And now I know it intimately. It’s not really a scientific question. The facts about death are unsettling. Yet as long as one is alive, there is no other way. The reason doctors can’t give their patients an exact prognosis is not just because they can’t. Of course, if a patient’s expectations are completely beyond what is reasonable – some people hope they will live to 130, and others see a small mole on their body and think death is imminent – doctors have an obligation to bring each other’s expectations back within a reasonable range of possibilities However, the reasonable range of possibilities is still very high. However, the range of reasonable possibilities is still very wide. Depending on the current treatment plan, I could die within two years, or I could last another 10 years. If you take into account the uncertainty of new treatments that may emerge in the next two or three years, the range may be completely different. When faced with death, scientific knowledge only provides an ounce of certainty: Yes, you will die. But there are always people who want a full pound of certainty, and that is not yet possible. What the patient is looking for is not the scientific knowledge that doctors hide from him or her, but the truth that each person must find in his or her own power that already exists. Being too deep in the data is like drinking salt water to quench your thirst. The indignation of facing death cannot be cured by unknown probabilities. I vividly remember a moment when the unease that was about to consume me suddenly and slowly subsided. It was then that I remembered Samuel Beckett. The nine words of Samuel Beckett, whose book I had read years ago when I was in college but had never properly read, came back to me clearly in that moment, and the seemingly insurmountable sea of uncertainty before me suddenly parted: “I cannot go forward. I will go forward.” I took a step forward and repeatedly chewed on the words, “I cannot go forward. I will go forward.” Then, at a certain point, I had an epiphany. Now, eight months had passed since the diagnosis. I have significantly regained my strength. In treatment, the cancer temporarily lay dormant. I gradually returned to work. I’ve dusted off my research manuscripts. I wrote more, I saw more, I felt more. Every morning at 5:30 a.m., as I rang the alarm and my rigid body awoke with my wife still sound asleep beside me, I would say to myself once again, “I can’t move forward.” A minute later, I had put on my scrubs and was walking to the operating room, still alive: “I will move forward.”