A lecture I gave recently about ethics and medical education’s hidden curriculum got me thinking about what we teach without really knowing it. There are very few classroom lectures that I can remember from my medical training, but I will never forget the day I followed a young physician as she walked into the room of a breathless elderly man, sat on his bed, touched his hair, and told him plainly that she had caused his complication.

“I’m really sorry,” she said, “but I screwed up and made a hole in your lung when I took that biopsy, and now I have to put a big tube in your chest. But I’ll do that right away and nothing else bad is going to happen to you.”

Nobody was teaching me ethics that day, nor explicitly teaching me how physicians should deliver bad news to their patients. Yet I was being taught something about honesty, forthrightness, responsibility, courage, accountability, and what it meant to be a physician. I didn’t realize it then, but I was being exposed to one aspect of medicine’s hidden curriculum.

Some define it as everything learners absorb that is not intended to be taught. A more formal definition might be: The hidden curriculum consists of attitudes, priorities, and values transmitted through everyday practice rather than formal teaching.

And, whether we recognize it or not, it is always at work.

The hidden curriculum is a form of education that shapes each and every individual, and there is nothing uniquely medical about it. Children hear parents tell them to be polite and kind, then watch them fall victim to road-rage or mistreat a waiter. Employees hear companies praise creativity but notice that disagreement is punished. Academics are told their universities cherish teaching, then are denied promotion because they have not committed themselves enough to research or publication. People tell their partners that honesty matters, then react badly when they hear something they do not want to hear.

The hidden curriculum is especially revealing when what we say we value conflicts with what is manifested by our behavior. The familiar saying that actions speak louder than words, however, is far too simple, because the hidden curriculum contains both. Words matter, of course, and people notice whether our behaviors confirm them. The positive effects of a hidden curriculum are most powerful, therefore, when stated values and everyday behaviors are consistent, avoiding the mixed messages we otherwise send to those around us.

For example, we may say that family matters, while repeatedly choosing work. We may stress that curiosity is a virtue, while ridiculing any display of potential ignorance. We may declare that independence matters, while rewarding only obedience, and stress the importance of humility while admiring bravado. Words like I don’t know, I was wrong, I need help, or we should stop, therefore, are not necessarily signs of weakness. They may instead reflect an emotionally safe environment where uncertainty, self-contradiction, efforts of reconsideration, and asking for help are not punished.

I’ve asked my students to think back to those individuals who most influenced their life or career. What do they actually remember? It is not how perfectly their bosses could recite a list of symptoms that make up a disease. Today, as artificial intelligence becomes increasingly capable of providing the explicit curriculum: information, facts and figures, and even aspects of reasoning, what we learn from watching other people may become relatively more important, certainly not less. What they remember most is how someone reacted in times of stress, how a colleague treated nurses, whether they took responsibility for mistakes, and whether they knew when not to proceed regardless of external pressures.

I’ve encountered the effects of the hidden curriculum many times, both within and outside the practice of medicine. In the high-risk sport of rock climbing and mountaineering, for example, I can only appreciate in hindsight some of those decisions made by my guides that kept me safe and alive. I can recall with admiration the friend who remained calm when things went badly, and the colleague who stayed behind to sit beside a frightened climber, abandoning an attempt for a summit that had until then been a lifelong dream.

Since giving the lecture, I’ve wondered about my own behavior and regretted the many times over the years when what I unknowingly taught others fell short of what I might have hoped to teach. But I am thankful too, knowing that for some of my colleagues, students, patients, friends, lovers, and family, some of what I have said or done might have felt inspiring, encouraging, or worthy of love, respect, or emulation.

That is what is both unsettling and comforting about the hidden curriculum, that none of us ever stops teaching it. In every relationship we occupy, in every role we choose to play, someone may be learning from us when we have no idea that a lesson is actually taking place.

· Lempe H, Seale C. The hidden curriculum in undergraduate medial education: Qualitative study of medical students’ perceptions of teaching. BMJ 2004;329:770.

They say, “never say never,” yet life shows us, often quite explicitly, that our existences are replete with “last times.” The last time we see someone. The last time we have a conversation with a parent, the last time we hold someone’s hand, enter our old office, or sit at dinner with a certain group of people.

Maybe that is why I felt so grateful for recently attending a scientific meeting where I was able to renew old friendships and share the enthusiasm of many much younger colleagues now entering my profession. After shaking hands with old friends or posing for photographs with new ones, I could not help but think about things past. I thought of patients I had lost, friends with whom I had shared but a portion of our life’s trajectory, and places I have been. I wondered what would change if we knew, while living a specific moment, that it would never happen again.

Some ends announce themselves. Graduations, retirement parties, and funerals. These are marked by rituals because all who attend understand and acknowledge that something (an education, a career, or a life) has ended. “Ein Mal jedes, nur ein Mal. Ein Mal und nicht mehr. Und wir auch ein Mal. Nie wieder.” “Once each thing, only once,” the German poet, Rainer Maria Rilke wrote a century ago. “Once and no more. And we too, once. Never again.”

But many of life’s endings come unannounced, without warning, ceremony, or even premonition. If Rilke wrote of the singularity and finality of our existence, the Argentine writer Jorge Luis Borges was more practical, and perhaps more unsettling. He tells us that “never again” happens all the time: the street already walked for the last time without knowing it, the person to whom we have unknowingly said our last goodbye.

“There must be one…/ That I by now have walked for the last time / Without guessing it…”

What troubles me, therefore, is that we usually recognize “never again” moments only in hindsight. Nothing about an ordinary dinner announces that a particular group may never sit together again. Nothing about leaving an office tells us we may never enter it again. A goodbye may sound exactly like every other goodbye before it.

Only days before my scientific meeting I had stood before the monolithic Moai of Easter Island, wondering whether it was not only the first, but also the last time I would gaze upon those stone statues whose origins remain bathed in mystery. This made me wonder, how many things have I already done for the last time?

I knew there were many. While a single tear on my cheek dried in the wind, I could not explain my sudden disarray to my guide. Perhaps it was linked to my age, knowing that at seventy I was statistically closer to the end than the beginning. Perhaps it was because I had already reflected on the mountains I knew I had climbed for the last time, the loved ones I had embraced one final moment, and, dare I say, the professional act I had apparently performed years ago for the very last time, but without ceremony.

And undoubtedly there were other lasts I did not yet know were lasts.

I wanted to reach out and hold those I loved and tell them, remember this, because this might be the last time.

But it is impractical to live with the belief that every experience may be happening for the last time. Of course, the injunction to seize the day or live each moment as though it were the last may be appealing, but it is virtually impossible to function normally while maintaining a constant awareness that what we are experiencing may never happen again. To surrender to such sentimentality would be unrealistic and emotionally unbearable. At the same time, acting as if each moment is its last risks altering the experience of the moment itself. And, besides, we rarely know with certainty that an experience, like the vanishing skyline of a city we have just flown from, for example, will prove to be final.

Perhaps that is why we have a tendency to linger. To let our eyes watch a moment longer. To stay just a few minutes more. To change how we say goodbye. Not because we know it is the last time, but precisely because we don’t.

· Rainer Maria Rilke. “Die Neunte Elegie.” Duineser Elegien. Leipzig: Insel-Verlag, 1923, Project Gutenberg.
· Jorge Luis Borges. “Limites.”In El hacedor: Emecé, (The Maker, 1960), trans. Alastair Reid.
“De estas calles que ahondan el poniente,/una habrá (no sé cuál) que he recorrido/ya por última vez, indiferente/y sin adivinarlo, sometido”

“Enough.” We hear the word constantly. It is used to express sufficiency, much like the Latin-based family of words that gives us sufficiente or suffisant, yet it can also signify the point at which something becomes excessive: to have enough, or not enough, of something…anything.

The English word derives from the Proto-Germanic ganōg and is related to an Indo-European idea of reaching or attaining something. It is not surprising, then, that modern dictionaries define enough in relation to a quantity or quality sufficient to meet a need, requirement, demand, or expectation. Nor is it surprising that the word carries two almost opposite emotional meanings: the satisfaction of having what we need, want or desire, and the moment when we have reached the boundary at which we can tolerate no more.

I have “enough” food, clothing, shelter, safety, even success. Some things have obvious limits. For example, we can only eat so much, within reason, and in truth, only a single roof is needed to stay out of the rain. But with most other things, what constitutes enough can be much more difficult to identify. How much money is enough? How much admiration? How many accomplishments are enough to feel a sense of achievement? How many more years would constitute enough life? And the funny thing is, if we are often quite good at singling out what we want, we can be considerably worse at recognizing the point at which we no longer need, demand, desire, require, or simply want more.

Perhaps the difficulty is that “enough” is neither a fixed quantity nor an easily definable quality. Enough money for security is one thing, enough money to feel successful is quite another. Enough recognition to feel one’s work matters is different from enough to know one’s life actually mattered. Enough accomplishments to warrant pride and personal satisfaction is not the same as sensing one has lived a purpose-driven life.

Philosophers have long attempted to distinguish desires that can be satisfied from those that cannot. According to the Ancient Greek philosopher Epicurus, some desires have natural limits, especially those generated from genuine human needs. Others, described by Epicureans as arising from groundless or empty opinion, such as the desire for great wealth, prestige, or fame, can expand indefinitely. This does not mean that wanting more is inherently wrong or pathological. Many great discoveries in art, science, exploration, and elsewhere result from people who, for whatever reasons, refuse to say “enough.”

The Stoics approached the problem somewhat differently. The Ancient Greek philosopher Epictetus distinguished between things that were within our power and those that were not, placing material possessions, reputation, and public standing among the latter. If “enough” depends on other people’s judgments, or if the measure of sufficiency lies outside our control, then any sense of fulfillment is likely to feel incomplete. Indeed, having enough money for security may be possible, but having enough money to feel secure may not be.

Contemporary philosopher Alain de Botton has reflected on the emotional toll that a constant striving for more can have on our psyche. For example, I may wish to write another book because doing so provides me with a sense of achievement. If, however, my need for recognition outweighs that sense, I might find myself constantly wanting to do more, rendering my personal satisfaction contingent on the behaviors and feelings of other people. Thus, any quest for status can become anxiety-provoking. It depends on where we stand, not as a measure of ourselves, but as a measure compared with other people.

Of course, almost no one operates from a single motive. Usually, we want to do, create, or experience something worthwhile, and we also want somebody to notice.

The difficulty is that the reference point may constantly be moving. At first, I want to publish my book, but then I want it to sell, then I want the book publicly acknowledged, then I want positive reviews, and why not, invitations to lecture at book clubs and public forums. What once seemed enough can become insufficient simply because the standard against which success is measured changes. No wonder the pursuit of more so easily troubles the human spirit.

The recent death of Nepalese mountaineer Nirmal Purja brought this question into particularly sharp focus for me. He died, along with nine other elite climbers, when they were caught in an avalanche on Pakistan’s treacherous 8,047-meter mountain, Broad Peak. The 43-year-old had already accomplished more in high-altitude climbing than most, yet his team continued its ascent in snow conditions that had prompted other teams to abandon their summit attempts. It would be far too easy to say that he misjudged the situation or should have decided to turn back because he had already done enough. Surely, he was no stranger to abandoning a summit quest when the risk-reward calculation had crossed a threshold. So why, on this day, had he not decided that enough was indeed enough?

Perhaps he was not seeking another accomplishment, another record, or higher status. Perhaps, instead, climbing meant far more than achievement, satisfaction, or glory. It may have represented his identity, his purpose, or his principal reason to feel alive. The meaning, then, of what is “enough” becomes considerably more complicated.

We speak readily of having enough money, food, success, experience, or recognition. Enough love. Eventually, even enough life. For most of these, the cost of losing what we have, or of never feeling that we have enough, may be dissatisfaction, anxiety, unhappiness, or a sense of wasted years. In climbing, as in other high-risk adventure sports, the cost can literally be a life.

Perhaps, then, enough is not primarily a question of quantity or quality, but of interpretation. The real work lies in asking what having “more” is supposed to give, what continuing to tolerate or pursue something may cost, and whether the answers we give to those questions are true.

· Epicurus. Letter to Menoeceus and Principal Doctrines. In Brad Inwood and Lloyd P Gerson, trans. and eds. The Epicurus Reader: Hackett Books, 1994.
· Epictetus. Handbook 1. In Discourses, Fragments, Handbook, trans. Robin Hard. Oxford University Press, 2014.
· Alain de Botton. Status Anxiety. New York: Pantheon Books, 2004.
· Nirmal Purja. 14 Peaks: Nothing is impossible. Documentary, Torquil Jones, Dir, 2021.

Vedic astrology, also known as Jyotish, has no scientific legitimacy, and there is no body of evidence to explain how the position of planetary bodies at the time of one’s birth might influence human behavior, personality, or destiny. Yet even today, this pseudoscience is highly regarded by millions of people. Its roots reach back to ancient India, where astrology, astronomy, and even architecture became entwined with religious and philosophical traditions concerned with karma and the course of human life. For centuries, people have turned to it for personal introspection, predictions about the future, guidance about careers and relationships, as well as for possible explanations for why their lives have taken the paths they have.

So why did I, a physician, practical philosopher, and lifelong skeptic, recently pay someone to read my Vedic birth chart?

Perhaps because I felt I was once more at one of the many crossroads we encounter during life. One where the decisions we make will surely contribute to our ability to find joy, happiness, and a sense of meaning in our existence. Usually, I look inward for guidance or rely on my desire to remain coherent with a philosophical nature built on concepts of virtue, integrity, and moderation. I don’t write prayers in the sand or explore the bottom of a cup of coffee for mysterious signals. I don’t wish upon a falling star, see messages in numbers, or crawl through prairies in search of four-leaf clovers. And I don’t seriously believe the planets’ locations can determine my life.

But if my life was not written in the stars, why does the life I’ve actually lived sometimes feel as though it could never have been otherwise? How can it be that listening to someone construct a narrative of my past and provide an explanation for my present sounds so real, as if it were all predetermined? Thinking about it more deeply, including my considerations of the astrologer’s predictions for my future, prompted me to confront something fundamental: we often construct narratives that make our choices, and even the accidents and coincidences of our lives appear inevitable after they have happened.

I’ve devoted most of my adult life to service and the healing professions. Motivated by neither money, power, nor status, my goal was to help people and make a difference in how medical professionals learned their trade. I was comforted, therefore, when I learned that I had also done so in past lives, although I had delved more deeply into alternative medicine and somatic healing. Perhaps that explained, I thought, my studies of acupuncture and homeopathy when I was a medical student, my explorations of psychology and philosophy since adolescence, and my deep-felt curiosity about the world’s religions.

The power of certain planets also helped explain my sense of well-being in the outdoors: my attraction to the sea, scuba diving, wilderness adventure, and mountaineering. Perhaps it explained my need to walk on the beach almost daily, and my perpetual desire to find comfort and peace while meditating against a long horizon, something I have done since I was a teenager.

As I recognized myself in the astrologer’s explanations, I saw a portrait that felt remarkably coherent. That is something philosophical practitioners try to achieve with our clients: helping them resolve doubt and uncertainty by making decisions that are coherent with their philosophy of life. But I also realized that we don’t merely want our lives to have happened. We want their disparate pieces to belong together. I wanted the physician, the philosopher, the mountaineer, the writer, the adventure traveler, the adolescent staring at the horizon seeking wisdom, and the seventy-year-old sitting before the astrologer to somehow be chapters of one intelligible life rather than a collection of accidents.

It did not matter whether this coherence was created through predestined existences, karma, personal choice, simple memory, or retrospective construction. Nor did it matter whether some of the astrologer’s apparent accuracies reflected little more than my own confirmation bias. What mattered, I thought, was the coherence itself. It gave substance to my existence by allowing me to see the life I had lived not merely as a succession of experiences, but as something that somehow belonged together. I could only hope for the same ahead.

That is what makes being at a crossroads both exciting and absolutely terrifying. One can look backward and make sense of many things, but making decisions that will someday keep our future coherent with our past is not always obvious, nor is coherence necessarily what we always want.

Of course, there are possibilities and decisions and, for those who are fortunate enough, choices within a framework of varying degrees of uncertainty. But there is also the reality of a future limited by hours, days, weeks, months or years left to live. Possibilities may remain open, but time never does. There are risks to reversing course, greater risks to beginning again, and sometimes even greater risks to simply waiting indefinitely.

The future isn’t written in the stars. But someday, perhaps, whatever happens will feel as though it never could have happened any other way.

· Nagesh Rajopadhye. Comparison of Vedic astrology birth charts of celebrities with ordinary people: an empirical study. International Journal Jyotish Research 2021;6)1):104-116.

Ever since I was a child, and throughout my life, I was taught to admire perseverance and celebrate those who refuse to quit. It started with encouragement to learn to walk despite braces on my little legs and continued with The Little Engine That Could, the first children’s story I memorized in its entirety. Later, my parents, teachers, and friends reinforced the same lesson: persistence was one of life’s greatest virtues: to keep on trying, no matter what. To stay the course, even in the face of adversity. Hang in there, they said, never quit, tough it out.

History is replete with examples of how persistence was ultimately rewarded with remarkable discoveries, great works of art, successful businesses, extraordinary expeditions, and enduring marriages. Just as importantly, almost every philosophy teaches perseverance. Christianity, Islam, and Judaism advise steadfastness. Buddhism teaches the value of disciplined practice. Stoicism praises endurance. Without a doubt, persistence deserves its reputation.

But the proclivity to persist can also be a trap, and there is another side to the coin of perseverance that is rarely discussed. Sometimes, we can persist for too long.

What I mean is that we rarely, if ever, know what the future holds. And because we cannot know the future, we cannot know whether one more day, one more conversation, one more investment, one more experiment, one more year will yield the results intended. Yet every physician knows the temptation to continue a treatment a little longer. Every writer has revised a manuscript that perhaps should have been abandoned. Every lover has found reasons to justify staying in a troubled relationship a while more.

And sometimes, we persist for too long.

The difficulty, of course, is that when we are in the thick of things, we cannot know if we are persisting too long or giving up too soon. This distinction becomes clear only in hindsight. The future remains unknowable. And as long as it is unknowable, possibility survives, and at the fulcrum of possibility lies hope. And hope makes stopping extraordinarily difficult.

In their early years, the entrepreneur who finally succeeds after ten start-up failures may feel the same as the businessman who ultimately loses a fortune chasing what turns out to be an illusion. The climbers who successfully continue toward the summit despite worsening weather may feel no differently from those whose decision to continue ultimately costs them their lives.

The challenge, therefore, is not in perseverance itself, but in having the capacity for good judgment when some of the criteria that define having made the “right” decision are only available in the future. This is because the outcome of a decision does not necessarily tell us whether the judgment behind it was good. A climber turns back, and the weather clears. Another continues and reaches the summit despite inclement weather. A physician makes a sound decision, yet the patient dies. Another makes a questionable decision, and the patient survives. Too many factors beyond our control, in addition to judgment, play a role in ultimate outcomes.

How sad that no one applauds the expedition wisely abandoned, the investment calmly avoided, the medical treatments thoughtfully stopped, or the relationships gently ended. There is no triumphant outcome by which to measure or celebrate these decisions, no way of knowing what might have happened had we chosen to persist. Often, there are only doubts and what-ifs. Yet these decisions may require as much, if not sometimes more, fortitude and judgment than staying the course.

Perhaps it is wrong to think of perseverance as an unconditional virtue. After all, the inclination to persist may be a strength of character, and its exercise a manifestation of a determined and tenacious personality. The danger lies in failing to recognize when perseverance has become stubbornness or psychological rigidity. The challenge, then, is knowing when to trust our inclination to persist and when to question it. This means having the ability to see issues from different perspectives and to take into consideration changing circumstances, hopes, past experiences, new evidence, and ultimate goals. It means knowing whether the thing being pursued remains worth pursuing and whether the reasons for pursuing it are still valid.

I was taught perseverance as a child. What life has taught me, however, is that perseverance alone is insufficient. What is harder to acquire, and even harder to exercise wisely in the face of uncertainty, is judgment.

· Alexander Pope. An essay on man (1732). Hope springs eternal in the human breast; / Man never is, / but always to be blest.
· Watty Piper. The Little Engine That Could. A Platt and Munk Classic (1954).

I have spent the past several weeks in Paris, walking more than I usually do, often without much purpose beyond “seeing” the city again. Paris rewards walking. Flâner, people call the process… strolling, and it has been an integral part of French literary modernity since the poet Charles Baudelaire extolled the qualities of the flâneur in his collection Paris Spleen, published posthumously in 1869.

But what did you do today? I’ve been asked repeatedly. Not much, is my usual reply.

It’s not that I wander aimlessly, however. Rather, I explore. I observe. In his masterpiece, In Search of Lost Time, Marcel Proust said that strolling and observing had a way to unlock memory. So, along my journey, I duck into vintage clothing shops, revel in the grandiose silences of ancient churches, and meander along sculpture-lined paths in museum gardens. Sometimes, I spend a few moments advising enthusiastic young people discovering the city for the first time.

Paris, after all, is a city designed to encourage admiration. Every neighborhood reveals another façade, another old building, another narrow street that suddenly opens onto a square. For me, it is a city of ghosts, of mournful recollections, but also of fond memories. Multitudes photograph buildings and bridges. Others look upward at stonework carved centuries ago and marvel that something so beautiful has endured despite war, revolution, and modern city planning.

While what is visible invites admiration, I began thinking that what is invisible often explains survival. As I wandered through different neighborhoods, I thus found myself wondering less about what I could see than about what I could not.

No building stands because of its façade. It stands because of foundations buried beneath the street, its load-bearing walls hidden behind plaster, and because generations of engineers, craftsmen, and laborers solved problems that helped these buildings endure. I felt this especially in the exposed underground structures and vaulted ceilings of the Collège des Bernardins, founded in 1245 and renowned as a theological school in the 5^th arrondissement. Like so many places elsewhere, the visible city rests upon an invisible architecture that most visitors never consider.

The more I walked, the more I realized that cities are not the only things built this way. Professions, institutions, habits, and even moral expectations rest on structures that have often disappeared from view.

Medicine, for example, is one such structure. We don’t always notice it because we inherit much of it, already built. Young physicians enter the profession with the assumption that things are because they always have been. Simulation belongs to training. Competency should be assessed rather than assumed. Informed consent is expected. What now seems obvious, however, was once inconvenient, disruptive, or even threatening.

In fact, none of these ideas arrived fully formed. Each represented a departure from what came before, requiring people to rebel against conventional wisdom, disrupt the status quo, persuade skeptical colleagues, organize institutions, develop curricula, and patiently convince others that a “new” way of doing things was possible.

Only then did ideas cease to be ideas. They became expectations, habits, and culture. Then architecture.

Until eventually, they become invisible.

This is when an idea no longer belongs to its originators. It belongs to the culture itself, and it is true in fields far beyond medicine. We wash our hands without recalling that physicians once dismissed the practice. We wear seatbelts and helmets because we no longer accept death as the ordinary cost of movement. We navigate cities whose water systems, energy grids, and transportation networks work quietly and unnoticed unless they fail.

The success of architecture lies in its gradual invisibility.

Strangely, this realization made me sad. Once an idea becomes part of ordinary life, we rarely remember the effort, the resistance, the imagination, and the relentless struggles it might have required to place it there.

Perhaps that is because architecture does more than exist. It influences behavior. A staircase influences movement and access just as strongly as curricula shape how students think long before they appreciate what is being shaped. In this way, what begins as architecture beneath a profession eventually becomes the profession.

Artificial Intelligence is the newest example. Much of the public conversation focuses on what AI will do visibly: whether it will diagnose disease more accurately and efficiently, or whether it will replace certain tasks. The deeper question is how AI is going to alter the invisible architecture of medicine itself: how medicine is taught, judgment is formed, authority is distributed, and how patients and health care providers understand what counts as knowledge.

These subjects stay with me during my walks. But I am no longer thinking about buildings, or even about medicine. I am thinking about the structures by which a life is quietly transformed.

As we age, we naturally take inventory. As we pass through each generation, those of us fortunate enough to grow older may think less about answering life’s questions than about understanding the structures and events that shape our answers. We recall visible accomplishments with joy, and sometimes, we remember visible failures with great regret. Neither may be what is most enduring.

What endures, perhaps, is less tangible, and as I’ve grown older, I find myself increasingly fascinated by what I might call those quiet transformations. They are more difficult to measure than dramatic moments, yet they can shape our futures more profoundly than visible achievements.

Each of us inherits an invisible architecture from family, circumstance, education, experiences, and time. It is built by parents, teachers, mentors, books, travels, friendships, and lovers. Experiences and places, too, may shape us long before we recognize their influence. In this sense, we can spend much of our lives adding to our architectural foundations. Yet, we may not always know exactly who or what prompted enduring change: a conversation that altered someone’s career. An idea that transformed someone’s life. A habit of thinking that spread from one generation to the next without anyone remembering where it began. Sometimes, even the greatest legacies can become invisible, and in so doing, they too become part of that invisible architecture.

I admit that I am not particularly comfortable with this thought. Like most people, I wanted my work to be seen. I suspect that desire is less about fame than about witness. We all hope, at least occasionally, that someone will notice the effort and sacrifice required to build something that did not exist before, professionally or personally. Not because recognition is the same as meaning, but because witness and validation reassure us that our efforts contributed to the world. We want to feel valuable, not because we changed the face of the universe, a role granted to only a handful of people, but because we did our best and because our efforts somehow mattered. To have such hopes is deeply human.

As I continue my wanderings about Paris, I thus find myself thinking less about monuments and more about foundations. I suspect that maturity brings with it a similar shift in vision. For much of our lives, we want to be seen. Later, for those who are fortunate, we may learn to accept another possibility: to endure not as a name, a monument, or a memory, but as something or someone quietly absorbed into another’s life.

· Stephan Bijan. In Praise of the Flâneur. The Paris Review (2013).

I haven’t shared much of my fiction here. Perhaps it’s time.

Like every morning, five days a week, Jerome kissed his wife before stepping out of her car and into the train station. His colleagues thought he was foolish to live in the suburbs, but high school sports programs in Westchester County were among the best in the country, and his sons were promising athletes. Besides, he liked the predictability of the sixty-minute commute into Manhattan.

He pulled his noise-canceling headset from his briefcase and slipped it over his ears. Between the ride and a brisk walk through Grand Central Station to the exit on 48^th Street, he would be at his Madison Avenue office in a little over an hour.

Just enough time to hear his favorite podcast.

He checked his watch. The train was crowded, the way it always was that time in the morning. Jerome kept to himself in his habitual corner seat. He recognized the usual faces. His neighbor, Ahmed, was already napping, and Margarite sitting bolt upright in her pinstriped suit and tulip skirt, iPad balanced on her knees. There were other familiar faces too, but Jerome knew nothing about them.

They were victims of habit, he thought.

They appeared where they always did, in the second wagon from the front.

He got to his feet and stepped into the aisle a few minutes before arrival. Jerome cradled his briefcase between his knees and put his arms into his overcoat, making sure his phone had not slipped from his pocket. He looked at his watch again, then stepped deliberately through the open doors onto the platform. Avoiding bottlenecks, he strode up the ramp to the main concourse and the hall leading toward the 48^th Street exit. It was no more than a ten-minute walk, so he thought about ordering coffee from the mobile kiosk, but on the way there he bumped into a teenage boy hurrying across the hall against foot traffic. Or rather, the boy bumped into him.

Jerome heard himself say, “I’m sorry.”

Deciding against coffee, he adjusted the collar of his overcoat and walked down toward the shoeshine booths in the Lower-Level Dining Concourse. The technicians were busy. He returned their nod and made a mental note to stop there tomorrow. Making his way to the east staircase, he adjusted his stride to avoid an elderly woman with her walker. He took the steps two at a time to the main level, then angled north toward the 48^thStreet exit.

At the base of a broad set of stairs, another man reached the first step at the same moment. Favoring the middle, Jerome’s pace quickened. The other man hesitated just enough. Jerome tightened the grip on his briefcase and edged ahead. He felt the familiar urge not to give way. No longer climbing two steps at a time, he moved quickly now, almost shuffling.

His toe clipped the lip of the final step.

Damn.

The bottom of his briefcase hit the granite floor. As Jerome lurched forward, his free hand reached for the rail but found only air. He was less than a breath from the ground when a hand caught his forearm and steadied him. He looked up and saw the other man, one hand on the railing, the other holding him. Both men stood squarely on the same step. Their eyes met only briefly. For an instant, Jerome felt the weight of his own body in another man’s grip. He couldn’t remember the last time another man had touched him.

At the top of the stairs, Jerome adjusted his overcoat and took hold of the handrail. He turned to say something, but the stranger had already stepped aside and moved toward Park Avenue. He looked familiar. Jerome had seen him before. He brushed the toe of his shoe against his pant leg and wiped the dust from his briefcase. Then he pressed his phone deeper into his pocket and merged into the crowd flowing west toward 48^th Street. He checked his watch. It was four blocks to his office at 51^st and Madison.

For most of human history, expertise was valuable because information was scarce. The village doctor knew things others did not know. The blacksmith could repair and build. The lawyer, architect, engineer, and professor spent years acquiring information not easily accessible to most people…and teachers possessed knowledge unavailable to students.

As a result, authority was built on the notion of scarcity. Those who knew were entrusted to share with those who knew less. Education of any sort was costly, long, and demanded sacrifice on the part of learners, and generosity from those who knew.

Knowledge, authority, and experience thus became tightly intertwined, each reinforcing the other and shaping society’s understanding of what constituted expertise.

Today, that is no longer the case.

As any parent knows, a teenager can learn advanced mathematics online. Patients often arrive informed about diseases and treatment once understood only by specialists. An aspiring investor can learn more from a conversation with artificial intelligence than years of consultations with a financial advisor.

The relationship between expertise, information, and authority has not changed solely with the arrival of artificial intelligence, although artificial intelligence certainly accelerated the process. It began decades ago with the internet, search engines, online education, digital communication, and the gradual democratization of knowledge. Historically, institutional greed, for most professions, was defined not only as wanting more, but as fearing the loss of what made those who were knowledgeable more powerful. It continues today, as an entire generation that denies their power base is ephemeral clings to older structures, even as they are being actively replaced by a younger generation, armed with cell phones, the cloud, and the power of “compute” in their quest to drastically alter the world in virtually every professional endeavor.

More than three decades ago, futurist Alvin Toffler argued that knowledge would become the dominant source of power in modern societies. What he could not fully imagine was a world in which access to knowledge itself would become universal.

Today, knowledge is everywhere, and within reach of virtually everyone. The traditional relationship between expertise and authority must therefore be reconsidered. Increasingly, we see greater emphasis being placed upon discernment, judgement, accountability, and responsibility. For years, these qualities were bundled with those of higher learning, experience, and authority. Because they were usually found in the same individuals, we assumed that qualities and credentials were inseparable.

Now, a young professional may have access to information that dwarfs that of their colleagues’ decades older. Students can fact-check their professors in real time. Writers can consult artificial intelligence for research, analysis, and editing in ways unimaginable only a few years ago.

The relationship between knowledge and authority can no longer be viewed as automatic.

The difficulty is that we have long treated knowledge, authority, experience, and judgment as though they were inseparable. They are not. They merely happened to reside in the same individuals for much of human history.

A teacher possessed knowledge and therefore held authority. In many cases this was accompanied by respect. A physician accumulated experience and became skilled at exercising good judgment. That prompted gratitude and again, respect. A business leader occupied a position of responsibility and thus commanded influence. When used for the good of others, here too, appreciation and respect ensued.

Authority and respect often traveled together, and because they did, we frequently confused one for the other.

The democratization of knowledge is not merely transforming expertise. It is transforming the foundations upon which authority rests. For centuries, authority derived much of its legitimacy from unequal access to information. As that inequality diminishes, authority can no longer rely solely upon credentials, titles, or institutional positions. Increasingly, it must justify itself through other means.

What those “other means” may be remains unclear. Perhaps authority in the future will depend less on what a person knows than on how and when that person uses their knowledge. Perhaps it will arise from transparency and understanding, rather than from exclusivity and demonstrations of presumed power differentials. Perhaps it will reflect accountability and responsibility rather than status, and wisdom rather than credentials. Perhaps respect, once granted automatically, or demanded by existing powers from those who possessed information when information was scarce, will need to be earned through character, good judgment, and service.

This question affects teachers, parents, physicians, politicians, journalists, business leaders, scientists, and anyone who hopes to influence others. It affects anyone who recognizes how a long-standing assumption that expertise justifies authority has become increasingly unstable.

We have entered an era in which information is abundant, and expertise is increasingly accessible and verifiable. Traditional hierarchies can and will be challenged from every direction. The question, therefore, will no longer be who possesses knowledge, because knowledge is available to everyone. The more difficult question is who deserves authority, and why.

· Alvin Toffler. Powershift: Knowledge, Power, and Violence at the Edge of the 21^st Century. Bantam Books (1991).

A few weeks ago, while preparing a lecture on apprenticeship, artificial intelligence and the future of medicine, I found myself thinking less about technology and more about generational shifts. For most of my professional life, the transmission of medical knowledge followed a pattern that changed remarkably little over the centuries. Access to medical school was competitive. In 1970s France, where I went to school, less than 30 percent of students had a baccalaureate, and among students in mathematics and the biological sciences yearly pass rates were below sixty percent. The first years of medical school were even more competitive.

Later, and throughout my medical training, students learned from residents. Residents learned from attending physicians and attending physicians carried forward habits of thought acquired from their own teachers. Interns wasted hours in medical libraries searching for and photocopying articles. We learned by standing beside people who knew more than we did. We were forced to memorize facts and clinical findings rather than refer to a patient’s medical record. Knowledge and authority were intertwined.

Expertise flowed, not always willingly or with educational talent, from those who possessed it to those who sought it. Clinical reasoning skills were absorbed through observation, correction, and gradual participation in increasingly complex decisions. Questioning the action or judgment of authority figures was often frowned upon. Technical skills were acquired gradually through repeated “practice” in real-life scenarios at the expense of patients themselves, or sometimes suddenly, which felt more like being thrown to the lions rather than nurtured by kindness, compassion, and understanding.

The process was imperfect, often inefficient, and frequently hierarchical to a fault, but it created a continuity of language, performance, and expectations that connected one generation of medical professionals to the next.

Today, that world feels increasingly distant.

A medical student with a smartphone has immediate access to more information than an entire academic department could muster with confidence a generation ago. Clinical guidelines, systematic reviews, procedural videos, educational lectures by some of the best teachers in the world, and increasingly sophisticated and accurate artificial intelligence systems can be consulted instantly. The democratization of knowledge has done more than expand opportunities for learning; it has reduced dependence on geography, institutional prestige or existing power maneuverings of authority figures.

During the preparation of my lecture, I became increasingly interested in what this means for mentorship. For generations, teachers and students shared a similar framework for the representations of knowledge, skill, and experience. Despite changes in technology and educational philosophies, this framework persisted within the core structures of medical professions. Today, however, we have entered a period in which mentors and trainees operate within fundamentally different epistemological systems. Furthermore, the life hurdles faced by younger generations are barely conceivable by their elders. As one physician-author suggested in a recent podcast, older generations are facing and fearing their eventual disappearance (through burnout, retirement, or death), while younger generations must face and fear their own obsolescence.

Similar transitions are occurring in other fields, such as journalism, aviation, and engineering. Experienced engineers once learned through lengthy apprenticeships and repeated encounters with failure. Contemporary engineers have access to simulation platforms and superhuman computational tools. Mastery of many traditional “legacy” methods has become less relevant than learning to innovate and benefit from new technologies through entrepreneurship.

The aviation industry presents another interesting analogy. Veteran pilots were trained during an era where manual control of the aircraft was of the utmost importance. Hours needed to be spent on flight simulators and in the air. Contemporary pilots, however, operate within highly automated systems where computers continuously assist with navigation, flight control, and safety monitoring. One need only watch the series For All Mankind to grasp a better understanding of new possibilities for remote and computer-assisted control of planes, drones, and space vehicles. Older pilots speak openly of the dangers of automation, and the importance of pilot expertise in the event of systems failures. Younger professionals, however, are less fearful of automation, than of learning to govern increasingly complex, overlapping systems that might operate unexpectedly in unusual circumstances or situations of uncertainty.

Whether in aviation, engineering, or medicine, as well as in many other industries and professions, twentieth century educational models were built on the premise that mentors primarily transmitted knowledge, technical skills, and a professional culture defined by a common language, actions and expectations mutually agreed upon with colleagues, students and trainees. Today, however, the challenge facing mentors is no longer merely the transmission of information, technical skill, or culture, it is to help younger professionals navigate an increasingly complex professional environment neither generation fully controls.

After all, today’s mentor is the last generation that remembers the world before abundance.

For this reason, mentorship during this current, ephemeral moment of generational shift, must look very different from the mentorship many of us have experienced. The mentor serving today operates at a generational interface; a transitional era between a time when knowledge was scarce and a time when knowledge is plentiful and immediately accessible. That mentor no longer serves as a gatekeeper of knowledge or an exclusive source of technical expertise, and any authority that once accompanied such an exclusive position has also dwindled.

The challenge for today’s mentors, therefore, is one for which they are ill-prepared. For the first time in centuries, they must guide students who inhabit a fundamentally different intellectual and educational environment from the one in which they themselves were trained. In many instances, their students are better equipped to navigate new technologies and complex computational systems. Their ability to access knowledge, navigate increasingly sophisticated AI and computational systems, and propose solutions to complex problems may also exceed that of their elders. For the first time in history, mentors and students may no longer operate from the same frame of reference.

This in and of itself may define the mentor’s role during this unusual period of transition, not as a gatekeeper, authority figure, or primary source of knowledge, but as witness and facilitator. Not to resist the future or nostalgize the past, but to help others cross the generational divide and face the challenges ahead with confidence. To provide perspective and living testimony to the emergence of a new world characterized by unprecedented access to knowledge and expertise, and to remind younger generations that every professional culture is the product of choices, traditions, constraints, successes, and failures.

That is the way.

· Pablo J. Boczkowski & Eugenia Mitchelstein. Abundance: On the Experience of Living in a World of Information Plenty. Oxford University Press (2021).
· Laurent Alexandre and Alexandre Tsicopoulos. Vivre 1000 ans : Quand l’IA règne et la mort recul : rêve ou cauchemar ? Buchet (2026).

Greed, which ancient Greek philosophers referred to as pleonexia, is an insatiable desire to have more (wealth, possessions, power etc). For many, this personality trait is both destructive and unjust. Socrates argued that greed prevented a person from being satisfied. Aristotle claimed that greed destroys communities because of the unfair distribution of material goods, wealth, and power. Stoics such as the emperor Marcus Aurelius said that greed, manifested as chasing things that are beyond our control, distracted from a life of virtue and reason. In his Meditations, Book VI, he writes “Alexander the Macedonian and his groom by death were brought to the same state; for either they were received among the same seminal principles of the universe, or they were alike dispersed among the atoms.” He thus extended the definition of greed beyond an irrational pursuit of wealth, power, and possessions to less tangible “assets” such as fame, recognition, or reputation.

But what about knowledge?

For centuries, medicine derived much of its authority from scarcity. Knowledge was difficult to acquire and unevenly distributed. It was, for the most part, inaccessible to anyone outside the profession. Training required years of apprenticeship. Medical texts were secured in specialized libraries. Expertise itself could only be accumulated after years spent accumulating information, experience, and technical skills. Society allowed for this monopoly, highly regarding and at times worshipping its healers, assuring them financial security, status, and respect. Because medicine concerns illness, suffering, and surviving much of life itself, practitioners and medical authorities acquired unusual powers regardless of their era, cultural environments or place of practice.

The physician possessed something others could not: the access to knowledge and the ability to interpret and technically apply it. Professional structures rapidly emerged to protect these particular abilities. Throughout the Middle Ages, physicians, surgeons, and apothecaries were organized into trade guilds that controlled pricing, authority, and training. These structures took on roles that would ensure public protection, practice standards, and quality. Access to medical expertise was limited by quotas and a need for long, costly apprenticeships. Scarcity, both of knowledge and of skilled practitioners was at the root of what some social scientists call “professional closure,” where a group declares itself the sole proprietor of a particular service.

In his Pulitzer-Prize winning book, “The Social Transformation of American Medicine,” sociologist Paul Starr described how modern American medicine consolidated its authority through standardized education, licensing structures, and effectively sidelining alternative practice systems. Other scholars suggest that professions preserve legitimacy not only through formal institutions, but also through asymmetries of knowledge, restricted access and specialized jargon not easily understood by outsiders.

History provides several uncomfortable examples. In the United States, barriers to professional membership deleteriously affected Black physicians until The American Medical Association officially amended its constitution and bylaws in 1968. Female medical students were subjected to quotas until the 1970s and passage of Title IX of the Higher Education Act. Patients lacked legal ownership of their medical records until passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996. It was not until 2022 that a federal mandate, the 21^st Century Cures Act, assured patients an immediate and free access to their complete electronic health information.

It would be unfair, of course, to conclude that Medicine developed its institutions through greed alone. For centuries, the profession has been shaped by individuals and organizations inspired by duty, an ethic of care, a quest for scientific rigor, and a genuine commitment to reduce suffering, improve longevity, and enhance quality of life. Yet professions, like individuals, can entertain competing motives simultaneously. Altruism and protection of status may coexist. A dedication to service and desires for authority may also coexist, as may acts of outward generosity and a predilection toward self-interest.

During my own career, I questioned whether medical knowledge achieved its highest ethical purpose when guarded or disseminated freely. My educational work arose from a simple conviction: patients should not bear the consequences of uneven access to training. Decades ago, I began thinking explicitly about democratization and understood that expanding access to expertise would inevitably challenge longstanding assumptions about scarcity, authority, and who has the right to control specialized knowledge.

The issues raised by democratization now confront medicine on an entirely different scale. Scarcity is no longer foundational to the guarantee and governance of medical expertise. Clinical studies are already accessible online. Patients read the medical literature and have access to their own data. Advocacy groups provide sophisticated understanding of diseases. Intelligence systems retrieve, synthesize, summarize, and compare information at suprahuman speeds. The physician’s role is changing rapidly, as is the spirit of each patient-physician encounter.

How medicine responds will shape not only clinical practice but the meaning of physicianhood itself.

Marcus Aurelius warned against greed for possessions, reputation, and the pursuit of things beyond our control. Perhaps he would recognize the temptation medical professionals face today: the desire to preserve authority by guarding access to knowledge in a world where scarcity itself is disappearing and knowledge increasingly seeks to become both free and more abundant.

Medicine, however, was never destined to derive its highest purpose from exclusivity. The deepest justification for expertise is not custodianship, but service. Future physicians, therefore, must be guides rather than gatekeepers, interpreters of uncertainty rather than guardians of knowledge. They must remember why society grants the profession its trust in the first place: not to possess knowledge, but to use it in ways that reduce suffering.

· Marcus Aurelius. Meditations. Encyclopedia Britannica, Great Books of the Western World (1952)
· Paul Starr. The Social Transformation of American Medicine. Basic Books (2017)
· Eliot Freidson. Profession of Medicine. A Study of the Sociology of Applied Knowledge. Dodd, Mead & Company (1970).

For most of human history, knowledge passed from person to person through direct contact. Observation, imitation, repetition, and gradual acquisition of technical skills and cognitive knowledge were a gradual process. Even the earliest forms of human learning emerged through observation and imitation of others: tool-making, shelter-building, navigation, the control of fire, and the gradual accumulation of practical knowledge across generations.

There was, in other words, a time when elders were valued for good reason.

This process shaped craftsmanship, music, dance, and the other arts, as well as law, medicine, engineering and virtually all professional endeavors. A younger or more junior individual stood by an older and more experienced one. They learned first by watching, then by doing. Over time, formal studies found their way into the process, as did testing.

What was transmitted, of course, is not knowledge itself, but also a way of thinking, prioritizing, judging, and acting under conditions of uncertainty.

Equally important and transmittable was reasoning. In each and every field, this action could be custom-built, modulated, and improved upon as learners gradually transitioned from novice to beginner, from beginner to competent practitioner, and onward, in some cases, toward expertise or mastery.

Together, knowledge, reasoning, and cultivated judgment formed what might be referred to as the rewards of cognitive apprenticeship.

To function independently, access to information was essential. Information retrieval, however, was slow, difficult, and expensive. Books only became more widely available, and at great expense, after the invention of the printing press in the 15^th century. But so was in-person apprenticeship. For most professions, medicine not excluded, training lasted years.

One learned not only by receiving information, but also by watching how information was used; by mentors, by colleagues, and by oneself, at first under supervision and then gradually, independently over time. Through this process, individuals acquired technical competence and learned restraint, judgment, and the gradual assumption of responsibility. It was also through this process that professional identity itself was formed.

The architecture of modern education emerged from this model. Teachers and senior figures were all-powerful and often authoritative, as power itself tends to corrupt and modify behaviors, not always in a good way. “Spare the rod and spoil the child” was commonly practiced, not only to discipline a child’s bad behavior, but also in more general settings to justify a practice of negative feedback or minimally acceptable standards. Educational systems evolved accordingly. University programs, licensure systems, certification examinations, continuing education requirements, and most competency assessments were built upon the premise that information needed to be memorized, retained, and internally organized before it could be integrated into helpful and constructive practice.

Artificial intelligence is fundamentally altering these assumptions.

Today, we are entering an era where knowledge is at almost everyone’s fingertips. Even sophisticated reasoning can be accessed without traversing the traditional formative stages of knowledge acquisition. In fact, knowledge is not only immediately retrievable, but it can be synthesized, summarized, and if necessary, translated into forms that are accessible even to those without advanced skills in a particular field, or adaptively explained at varying levels of complexity depending on the background of the learner. The danger, of course, is that conclusions may be derived before the learned person has independently constructed the reasoning that once produced them.

There was a time, therefore, when information had to be internalized and retained because access itself was constrained. Knowledge became inseparable from memory and from the gradual development of reasoning processes within an individual, under guidance and with mentoring. The learner was responsible for processing information. Teachers were responsible for assuring the process and monitoring the results.

Artificial intelligence has changed those relationships.

What is changing, in fact, is not simply access to information. It is the relationship between information, reasoning, and responsibility. Increasingly, individuals can access sophisticated, synthesized reasoning without traversing the long, formative pathways through which expertise has traditionally been acquired. In some domains, a major question will not be whether expertise disappears altogether, but rather which dimensions of expertise will remain uniquely human.

Today, learners need not reconstruct every intermediate step in order to reach a functional decision. An amateur without a degree in information technology can generate, through the use of artificial intelligence, code with which to write an application that might go viral. A patient may come to see their physician already armed with a diagnosis and management plan; sometimes requiring only confirmation or a prescription for ancillary tests and medications.

Even creative fields are changing, as musicians, filmmakers, and visual artists see “amateurs” use computer-based systems to generate polished works, endless imitations, and original themes and variations without the grueling years of imitation, revision, failure, critique, and gradual skill acquisition once required through apprenticeship-like training.

In my own field, which is medicine, these changes are truly revolutionary. They will alter what is learned in medical school. They will change how competency is determined and measured, how licensure is granted, and how professional status and expertise are judged. Many existing structures of academic and professional authority will resist these changes, because systems built upon older models of expertise rarely surrender their inherited authority willingly. But transformation is already underway, and the proverbial horse has long since left the barn.

The challenge is not to rein in the animal, but to learn how to ride.

· Donald A. Schon. The Reflective Practitioner. How Professionals Think in Action. Basic Books (1983).
· Jean Lave & Etienne Wenger. Situated learning: Legitimate peripheral participation. Cambridge University Press (1991).

We learn, in most domains of modern life, to believe that uncertainty is temporary. We hope that with enough time, enough data, enough consultations with friends, family and experts, the correct course will reveal itself. Even our psychology has adapted to this expectation, so that uncertainty is experienced as an uncomfortable state the mind strives to resolve. Ambiguity becomes aversive. Perceived threats are overestimated. Heightened vigilance, anxiety, and rumination emerge as deeply rooted responses instilled in our behavior over millions of years, to help us deal with the unknown.

In some settings, these patterns may cause high-grade anxiety. Even rigid decision-making, unalterable biases, compulsive information-seeking, or avoidance stem from our quest to control uncertainty. We may cling to extreme positions, defer decisions indefinitely, adopt sometimes strange but often habit-forming rituals, or seek reassurance wherever it can be found. Our goal is to convert uncertainty into something more reassuring, more predictable, and more tolerable.

These tendencies are reinforced by the fact that society rewards “certainty.” We preferentially tend to think in black and white. Problem-solving comes more easily when issues are perceived as binary choices. Technologies promise clarity. Cultures equate good judgment with being well-informed. Living “in the gray” is generally discouraged.

We are taught to believe that if we only knew more, or if we only understood better, all ambiguities would be resolved. We might turn inward for inspiration through meditation, mindfulness, or belief or outward, to data and expertise in our hope that more knowledge will provide solutions.

In clinical practice, we rely on evidence, guidelines, consensus, and accumulated experience to gain clarity. Risks are often quantifiable, but not with absolute certainty. A patient lies before you. The data are available but not decisive. Multiple pathways are acceptable. Each potential management option is defensible, but none is clearly correct. One does not (yet) have the privilege of hindsight.

Just as in life where some decisions are defined by limits of knowing, in medicine, decisions cannot always be based solely on tools, data, or protocols. One must accept that reasoning becomes intensely personal, shaped by interpretation and by how experience has informed understanding.

This is what we call judgment.

The structure is not unique to medicine. Patients encounter it when they are faced with choices among alternatives they do not fully understand. Families experience it when they weigh interventions whose outcomes cannot be predicted. And in life, whenever decisions carry significant weight and potentially irreversible consequences: whether to remain or leave a relationship, to quit one’s job, and to alter the trajectory of one’s life in ways that are not readily undone.

The specifics differ, but the structure remains. A decision must be made. Risks may be estimated, but certainty is not available. Even inaction is a form of action.

What remains, then, as a basis for decision?

Not certainty. Not complete knowledge. And if experience has taught us that instinct and intuition are not infallible, then something else must carry the weight.

What remains is our reliance on internal structures: habits of thinking, a tolerance for ambiguity, and our capacity to remain steadfast in the presence of the unknown. These skills are not easily acquired. They develop over time. For some lucky few, they are shaped with the help of a spiritual guide, a mentor, or some deeper philosophical or spiritual framework.

Regardless, in the end, when decisions cannot be made on solid ground, they require a willingness to act without full justification, and with that act, a willingness to accept responsibility for all that follows.

· William James. The Will to Believe (1896).
· Daniel Kahneman. Thinking, Fast and Slow (2011).

Medicine is no longer defined solely by what physicians can do, but by how they assume responsibility for the decisions they make within increasingly structured, technology-driven systems.

Many medical specialties, including my own, which is interventional pulmonology, are defined by technology: instruments, robots, scopes, and a multitude of imaging technologies. These tools allow health care providers to see into spaces that were once inaccessible. From the stethoscope to modern computed tomography scanners, they represent progress in its most visible form. But identities are also defined by actions: what practitioners can do as well as what they should do. Both emerge from the tools they use and from how they are trained to use them.

If we step back, however, something else comes into view. As medical landscapes change, professional identities begin to shift. For example, the modern interventional pulmonologist does not enter an open field. They enter a structured environment where algorithms guide evaluations and disease management. Imaging studies are more sophisticated and precise. Institutional protocols and multidisciplinary plans of care based on evidence-based results from larger population studies often guide decision-making before the physician ever meets the patient.

The physician, therefore, occupies a role within a structured system in which information is often immediately accessible and outcomes are more predictable. As what can be done expands, the burden of deciding what to do intensifies. Data integration is largely automated. In many instances, what should be done becomes less uncertain. Furthermore, artificial intelligence is beginning to shape how data are presented and how decisions are framed. Overall, systems are becoming more predictive. In this increasingly structured environment, something less measurable is easily overlooked: the unstructured human encounter on which medicine has always depended.

This shift becomes clearly visible in ordinary clinical decisions. Consider something as familiar as the management of a pulmonary nodule. Perhaps it was discovered incidentally when the patient underwent a coronary calcium scan while screening for coronary artery disease, or perhaps it was discovered during chest or whole-body imaging for other reasons. Risk models estimate malignancy. Imaging studies highlight features of concern. Guidelines suggest surveillance or biopsy. Evidence-based studies justify which biopsy techniques to use. Order sets are proposed.

By the time the physician meets the patient, the clinical setting has been at least partially defined. Much of the decision has, in effect, been organized in advance.

And yet, the clinical problem is not fully solved.

What remains is a question of consequence for the individual patient. It is a question whose answer does not rely solely on a medical practitioner’s accumulated knowledge, capability, or technical skill, but on their judgment. Responsibility remains with the physician, even as the conditions under which decisions are made are increasingly shaped by forces beyond individual control.

The physician’s identity, therefore, is less anchored in what they do, but in how they assume responsibility for what will be done. Many patients come to the consultation room having already engaged with AI systems that organize medical knowledge. They also come with their own particular fears, biases, concerns, and medical histories. As decisions are increasingly shaped by systems that extend beyond the individual practitioner, however, health care providers must still interpret, question, and choose among management alternatives. They must be able to communicate effectively with patients who now arrive more informed, engaged, and influenced by external systems that were once beyond their reach. They must recognize that while systems can organize information, suggest pathways, and weigh probabilities, they do not (yet) bear responsibility.

That remains strictly human.

· MacMahon H, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images. Radiology. 2017;284(1).
· Topol E. Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again. Blackstone Publishing, 2019.

This essay accompanies a recent video lesson exploring these ideas in greater depth—particularly the evolving role of judgment in interventional pulmonology.

Watch here: Who Are We Becoming

On April 10, the now seventy-year-old child in me was awakened as I watched the space capsule Orion touch down in the Pacific Ocean off the coast of San Diego. I marveled at how four NASA astronauts had voyaged around the far side of the Moon and back, spending ten days in space and taking their Artemis II spacecraft farther than any manned flight had gone before, 252,756 miles to be exact.

I recalled a similar enthusiasm fifty-seven years ago. I was thirteen and in a small hotel in Washington, D.C. with my father. The day had already been memorable, marked by my visit to the White House and Arlington National Cemetery. It was 10:56 p.m., July 20, 1969. Only hours earlier, the Eagle lunar module had separated from Apollo 11’s command module, Columbia, and landed in the Sea of Tranquility. My eyes had been fixed on the television screen all evening. I was overcome with excitement when Neil Armstrong set foot on the Moon’s surface.

“That’s one small step for man, one giant leap for mankind.”

What I could not imagine then, watching the grainy black-and-white image from my hotel room in Washington, was that the journey to the Moon would not end at the lunar surface. It would influence the environment in which I would spend fifty years caring for others; in hospitals and clinics, in operating rooms, and in remote settings. It would shape how we monitor, diagnose, and care for patients. The medical legacy of the Mercury and Apollo eras, and more specifically the entire space program, is woven into how we practice and teach medicine today.

For example, the need to monitor astronauts continuously in an environment where direct intervention is impossible led to the development of telemetry systems that fostered modern telemedicine and remote patient monitoring. The need for miniaturization without sacrificing function drove innovations in electronics and digital signal processing which ultimately led to the development of portable and implantable medical devices, as well as advances in imaging, guidance, and remote sensing.

Material science innovations also had a direct impact on medicine. They shaped the development of automated medication injectors, scratch-resistant optical lenses, and prosthetics. Memory foam emerged from efforts to manufacture lighter, more comfortable crashproof materials capable of absorbing impact within spacecraft. Innovative laser technology would find applications in medical diagnostics and therapy. Even the need for biologically safe, lightweight nutrition during prolonged missions led to improvements in food preservation, such as vacuum-sealing, freeze-drying, and contamination control.

Just as importantly, the culture that nurtured these scientific efforts was based on a need for redundancy, precision, and the understanding that failure often carried irreversible consequences. Just as the constraints of spaceflight fostered solutions that would reshape medical practice, this culture found its parallel in modern medicine, where safety, reliability, and systems-based practice became central to clinical care.

Today, the relationship between space exploration and human health continues to evolve. Beyond engineering breakthroughs, NASA’s Human Research Program focuses on astronaut health and performance in preparation for extended lunar missions and missions to Mars. Research in radiation biology has downstream implications for oncology, radiology, and nuclear medicine. Organ-on-chip systems like AVATAR, which uses astronaut-derived cells to model tissue-specific responses to deep space stressors, may deepen our understanding of disease mechanisms and form a bedrock for precision medicine, an approach that tailors care to the individual rather than the “average” patient.

The Artemis missions, including planned lunar landings, provide further opportunities to study physiologic and behavioral adaptation in extreme conditions. A focus on sleep, cognition, and interpersonal stress in confined environments is relevant to health care providers working in the intensive care unit, emergency settings, surgical practice, and wilderness or expedition medicine where performance and human judgment are tested under pressure.

There are many other areas in which space exploration continues to generate knowledge that will shape the future of medicine. Yet its deeper significance lies elsewhere. It resides in the human impulse to look toward the unknown and to imagine ourselves beyond present constraints, which, itself is an expression of our restlessness and spirit of adventure. In that sense, the legacy of space exploration is not solely technological, but human. It invites us to look to the sky, not only to dream or to see the stars as destinations, but to extend ourselves beyond what is known, echoing the instinct captured in Star Trek’s call to boldly go where no one has gone before.

· Nicogossian AE, Williams RS, Huntoon CL, et al., Eds. Space Physiology and Medicine.4th ed. Springer; 2016.
· NASA Biological & Physical Sciences. AVATAR (A Virtual Astronaut Tissue Analog Response) (updated 2025–2026 materials).

In my previous essay, I asked a question patients often ask, but cannot easily answer with confidence: Who is the best doctor for me? I noted that the absence of transparent risk-adjusted outcomes (results data) contributes to this uncertainty, particularly in regard to minimally invasive or invasive surgical interventions. Yet, even if these data were readily available and accessible for all specialties, procedures, and institutions, the question itself would still remain, for the most part, unanswered.

That is because excellence in medicine is not confined to what can be measured. Of course, medical society-based registries may capture complications, mortality, specialty-identified satisfactory outcomes, and other “measurable” endpoints at the institutional, aggregate, and occasionally, individual level of physicians. Institutions too may be ranked in terms of patient safety, user experience, staffing, clinical outcomes, or reputation in specific high-risk as well as common procedures. Examples abound in rankings from publications such as US News & World Report, Healthgrades, and Leapfrog to name but a few.

But when patients wonder, who is the best doctor for me, they are not only asking about technical skill and procedural success rates. They are often asking, without necessarily being explicit, about something more fundamental and harder to quantify. They wonder whether their health care team will act skillfully, but also with discernment. Will their physician recognize the limits of intervention as well as consider its alternatives? Will they know when to proceed, how to choose, and when to pause.

They are, in truth, asking about something not easily defined by metrics and algorithms. They are asking about something that is intrinsically human. They are asking about character.

No matter what might be said, medical institutions and health care services are businesses that reward productivity, albeit in many shapes and sizes. Procedural volume, for example, might be linked to financial incentives, professional advancement, and reputation. Return on investment is routinely calculated before equipment purchases, investments in clinical services, or implementation of new technologies. While patients may equate innovative interventions or the use of modern diagnostic tests as state-of-the-art care, physicians remain faced with the eternal dilemma: This can be done, but should it be done?

This dilemma is faced daily in clinical practice. Consider the patient with a small pulmonary nodule of uncertain significance. The physician has the technology and skill to navigate to its location, obtain tissue, and provide an answer. The probability of malignancy may be low, even extremely low. The risks of intervention, while small, can almost never be entirely negligible. Surveillance may be reasonable. So too may be intervention. Medical evidence justifying either approach might be available or may depend on one’s interpretation. No algorithm may fully resolve the tension.

In such moments, the physician must weigh probabilities against consequences. Guidelines versus individualized decision-making. Motivation versus reward. The decision is not merely technical.

And often, it all boils down to an act of judgment.

What then is a patient to do? Of course they will seek out physicians with appropriate training, experience, and institutional support. They can ask about outcomes, sometimes at the risk of alienating that occasional health care provider who does not appreciate being questioned. They can listen to what is said as well as how it is said, which demands ample time with doctors who unfortunately don’t always take the time to sit, explain, empathize, and understand. They can acknowledge the uncertainty of medical decision-making, and they can ask themselves about whether the physician’s way of thinking aligns with their own values and preferences.

Patients used to rely on primary care providers to help them make decisions. For decades, family doctors and internal medicine specialists helped coordinate patient care. Both formally and informally, they would guide patients through the maze of medical care and cope with an increasingly complex specialized system. Their longitudinal relationships with patients and patients’ families helped weigh competing opinions, and placed treatment recommendations in their appropriate context.

That structure has eroded. Today, a substantial portion of Americans lack an established primary care provider, and it takes weeks and often months to make an appointment with a physician. Additionally troubling is that the American Association of Medical Colleges estimates an overall physician shortfall of up to 86,000 by 2036, with primary care providers among the most affected sectors.

The specialist has thus become not only the consultant and person who performs the procedure, but also the decision-maker.

In that role, the question of who is best cannot be answered by rankings, credentials, or outcomes data alone. It depends on how the physician navigates uncertainty, weighs existing and hypothetical risks, and makes decisions when more than one reasonable path exists. This is not a matter of technical skill, but of judgment. And judgment, in the end, is an expression of character.

· The Complexities of Physician Supply and Demand. Projections from 2024-2036. A summary report. AAMC, March 2024.
· Closing the Primary Care Gap. How community health centers can address the nation’s primary care crisis. NACHC, February 2023.

There is a particular stillness in the faces of Amedeo Modigliani’s portraits. Elongated and instantly distinguishable by their hollowed or pale blue eyes, with heads tilted like flowers resting on thin, swan-like necks, they now grace the walls of the world’s greatest museums.

They were painted in the early years of the twentieth century. Many carry an unspoken fragility — a sense of life both vivid and already receding, much like their creator. Modigliani (1884-1920) himself lived with a sword of Damocles suspended above him. Diagnosed at a young age with Mycobacterium tuberculosis (Mtb), then called phthisis or consumption, he understood that his life would likely be short. He died at thirty-five, presumably from tuberculous meningitis. He was one among millions living in an era when tuberculosis moved through crowded studios and dimly lit homes, carrying with it the weight of incurability, poverty, stigma, and isolation.

Today, on World Tuberculosis Day, his life invites us to reconsider what it means to see, rather than overlook, a disease that has never truly disappeared.

Mycobacterium tuberculosis establishes itself within the lung, provoking a granulomatous response that attempts containment but often fails to eradicate the organism. In approximately ten percent of infected individuals, host defenses are unable to contain the infection, and active disease develops. Over time, caseation, necrosis, and cavitation disrupt normal lung architecture. Patients develop a persistent cough, sometimes accompanied by hemoptysis. Systemic symptoms, such as fever, night sweats, and weight loss, reflect a sustained immune response.

In the late eighteenth and nineteenth centuries, the visible manifestations of the disease, such as pallor, thinness, or a febrile flush, were paradoxically aestheticized. Fashion adapted. Women emulated what became known as “tubercular chic,” using corsets and pale cosmetics to approximate the appearance of illness in the pursuit of beauty.

Tuberculosis did not spare the gifted. The English poet John Keats died of tuberculosis at the age of twenty-five. Anton Chekhov, himself a physician, lived with the disease for years before succumbing to it. So too did the authors George Orwell, Emily and Anne Brontë, Katherine Mansfield, Franz Kafka, and Thomas Wolfe. Even Austrian physicist Erwin Schrödinger and the actress Vivien Leigh (star of the films Gone with the Wind and A Streetcar Named Desire) were marked by it. In each, tuberculosis was not merely a disease, but a lens through which life was perceived and lived.

In my book, Becoming Modigliani, I argued that the artist’s awareness of an early death, together with his chronic and sometimes incapacitating symptoms, contributed to a self-destructive intensity translated by an urgency that shaped both his life and his art. Today, fortunately, early diagnosis and effective treatments are available. Molecular assays allow for rapid detection and identification of drug resistance. In many cases, standard six-month regimens achieve cure rates exceeding 85% for drug-susceptible organisms, and when adherence to treatment is maintained.

And yet, tuberculosis persists.

According to the World Health Organization, more than ten million people are infected with tuberculosis each year, and in 2024 alone, at least 1.23 million deaths were attributed to the disease. Despite this, tuberculosis is often misperceived as a relic of the past or as a condition that affects only specific, marginalized populations. In many developed nations, including the United States, it is no longer widely regarded as an immediate threat.

This perception is mistaken.

Tuberculosis remains the leading cause of death from a single infectious agent worldwide. It is an airborne disease, transmissible to anyone, though amplified by conditions such as weakened immunity, poverty, and limited access to care. That it continues to persist is not merely a failure of medicine, but a reflection of broader social realities — those of inequity, neglect, and the politics of exclusion.

We once romanticized this disease. We rendered it aesthetic, even desirable in its outward signs, while ignoring its suffering and often ostracizing its victims. Today, we have done something different, but no less troubling.

We have forgotten it, and in doing so, we risk allowing a curable disease to remain unconquered.

· Henri Colt. Becoming Modigliani. Rake Press (2025).
· Carolyn A. Day. Consumptive Chic. A History of Beauty, Fashion, and Disease. Bloomsbury Publishing (2017).
· World Health Organization. Global Tuberculosis Report 2025.

Physicians who earn their living performing procedures are trained, above all, to intervene. Their work unfolds in a visible theater where success is measured in terms of witnessed dexterity, decisiveness, and outcomes. Yet, beneath the technical stage of the procedure room lies another theater, less visible but often just as important. It is a moral and relational one bound by personal ethics, professional judgment, and the capacity to defend, withstand, or reconcile institutional pressures.

This, however, is the subject of a different essay.

Proceduralists are rarely one thing. First and foremost, they are technicians, of course, and patients understandably would like to choose them on that basis. Often, patients express the desire to choose their doctors based on published results of technical successes. Strangely, however, only a handful of surgical fields offer robust, publicly accessible risk-adjusted outcomes data that patients can use to compare institutions. Even fewer allow meaningful comparisons among individual physicians. Cardiac and thoracic surgery is the clearest example. Others include bariatric surgery, orthopedics (for joint replacement), transplant surgery, and oncology care through cancer registries and hospital rankings. Each offers varying degrees of transparency and accessibility to individual patients.

A few recent observations of physician practices in my own specialty, which is interventional pulmonology, prompted me to write this introductory essay. In recent years, rapid growth, driven in part by technological progress, has enabled earlier diagnosis of diseases such as lung cancer and improved the ability to palliate, and sometimes cure, patients with benign and malignant central airway obstruction (tracheal and bronchial tumors). The procedural repertoire is growing, and with it, the promise of even more meaningful clinical impact.

Yet the specialty still lacks a national, publicly accessible outcomes registry.

This absence is easy to explain. Considering the difficulties encountered in standardizing outcomes and adjusting for risks, the challenges are substantial. Clear endpoints, such as mortality and procedure-related complications, must be defined. Sufficient procedural volumes to make statistical analyses meaningful are required before even contemplating the creation of such a database. Risk adjustments must account for the heterogeneity and severity of diseases and the frequent coexistence of other medical disorders. Standardized techniques must also be identified, even as innovation continues to reshape clinical practice. Perhaps interventions such as bronchoscopic ablation of an airway tumor, or airway stent insertion using a particular device are good places to begin, as both are performed in academic and community-based practice alike. Most importantly, embarking on such an endeavor demands coordinated leadership and the enthusiastic support of the medical specialty’s professional societies.

As of now, however, patients who require these often life-altering or life-saving procedures have little knowledge about how to best choose their doctors.

I find it increasingly puzzling, therefore, that a profession that prides itself on evidence-based decision-making, statistical rigor, and life-long learning after prolonged apprenticeship-style training, is unable to provide patients with what they want most — the answer to their question:

“Who is the best interventional pulmonologist for me?”

This essay is the first in a short series exploring how patients choose procedural physicians, and what current systems of measurement fail to capture.

The phrase legacy thinking carries two very different meanings. One is forward-looking and generational, the other is focused on past performances and traditions.

Legacy thinking is often described as a way of thinking about the future, especially when it involves leaving something behind for the next generation. In this sense, it is forward-looking. A physician may hope to pass along to trainees a respect for professional traditions, a sense of responsibility, and habits of disciplined work. They may also wish to transmit a commitment to treating patients with compassion, colleagues with respect, and an approach to scientific inquiry grounded in curiosity and evidence before action.

Understood this way, legacy thinking treats time as a continuum in which one generation consciously prepares the ground for the next. Mentors thus pay close attention to how their actions might shape their students’ values and behaviors. Teachers hope their students will emulate not only what they know, but also how they think. Strong institutions might strive to foster environments in which individuals may prosper financially, emotionally, and intellectually. Families strive to cultivate relationships grounded in love, generosity, and trust.

Yet the same phrase can mean something quite different. Legacy thinking can also refer to the habit of staying anchored to the past. In this sense, it means hoping or presuming that habits and ideas that once worked will continue to work indefinitely. Traditions are abandoned with difficulty. Individuals resist change or construct obstacles that prevent it altogether. Entrepreneur Salim Ismail describes this as an “immune system” problem: when disruptive ideas enter established systems, the system reacts defensively in order to neutralize the threat and restore familiar patterns. It happens in research, business, and interpersonal relationships.

Individuals behave the same way. Even forward-looking thinkers might hold on to old ideas. Those once known for their creativity can become entrenched in outdated assumptions and behaviors. Instead of building for the future, they focus on preserving the present. With their credibility and power gained from decades of work, they may find themselves still influencing others and defending territory— intellectual, behavioral, or emotional—even when the surrounding world has already changed.

I’ve been thinking a great deal about change recently. Perhaps it is because I am growing older. Or perhaps it is because technological innovation is transforming daily life at an extraordinary pace. Influencers shape cultural preferences. Podcasts expand educational opportunities almost exponentially. Digital assistants help complete mundane tasks with remarkable efficiency.

Each new generation faces the challenge of deciding what should be preserved, what should be discarded, and what warrants adaptation. These decisions often create tension between those who are embedded in the past and those who advocate change. Early adopters sometimes embrace innovation at considerable personal or professional risk, while others remain anchored to familiar habits and safer havens. Those who resist change for too long may eventually find themselves sidelined, increasingly irrelevant, and at worst obsolete, although many may persist for years due to their established authority and institutional influence.

At certain moments in history, however, disruption occurs so rapidly that gradual adjustments become impossible. Clayton Christensen described this phenomenon in The Innovator’s Dilemma, where disruptive innovation upends established practices and assumptions in some of the world’s best-known companies. We are living through such a moment now. Artificial intelligence is rapidly reshaping how we learn, work, think, communicate, and create.

In my experience as a physician, teacher, and writer, healthy legacy thinking transmits principles rather than habits. Principles endure even as methodologies, tools, and techniques evolve. This belief shaped the founding of Bronchoscopy International thirty years ago, built on the principle of democratizing knowledge and the ethics-grounded conviction that patients should not bear the burden of procedure-related training.

As I look back on five decades of work as a physician and teacher, I realize that very few of the techniques I learned early in my career remain unaltered. Tools change, technologies advance, and new knowledge replaces old. What endures is a deep commitment to serving others and a life grounded in curiosity, humility, and responsibility. If anything I have tried to build continues to matter in the years ahead, I hope it will be because a few seeds were carried forward by others who choose to cultivate those same principles.

· Clay Christensen. The innovator’s dilemma: When new technologies cause great firms to fail. Harvard Business Review Press, 2013.
· Colbert Cannon. Salim Ismail. https://www.hpspartners.com/insights-and-news/s10ep96-salim-ismail. April 10, 2024.
· Bronchoscopy International. https://bronchoscopy.org

The Presocratic philosopher Heraclitus is famous for saying that one can never step in the same river twice, which implies that both the river and the person stepping into it are constantly in a state of flux. A more modern reading of his work suggests something more subtle: that some things endure only by changing. A river remains a river precisely because its waters flow.

So it is in medicine. We should not be surprised, therefore, that a physician’s professional life is not static, but a sequence of transitions. From student to clinician. From junior attending to senior physician. From confidence in scientific certainty to the humbling understanding that discovery, like human relationships, is provisional. What appears certain today may not always be tomorrow’s reality.

Somewhere along this continuum, many physicians encounter burnout. This phenomenon is not the sole province of the medical profession, but its consequences here can be profound.

Life seems to have less meaning. Work is performed with less purpose. The patient becomes a diagnosis. The encounter becomes a task, or worse yet, a burden.

In its early stages, burnout may appear as fatigue or irritability. Over time, it evolves into emotional distancing and depersonalization. Physicians may find themselves referring to their patients by case number or disease type rather than by name, building protective distance in order to preserve emotional energy. Time at the bedside might be converted into time behind a computer. The need for careful charting becomes a ready excuse for avoiding prolonged face-to-face engagement. Eventually, the pursuit of efficiency replaces the need or desire for intimacy.

The causes for burnout are rarely singular. Long hours, administrative burdens, institutional constraints, system unfairness, and a hostile or unrewarding work environment, as well as the relentless demand to achieve and maintain competence, exert external pressures. Yet burnout becomes something more than the inability to successfully overcome such challenges. It is the experience of identity strain: the growing tension that comes after realizing one is no longer the person one had set out to be.

Transition, therefore, becomes not only desirable, but necessary. Today, trainees have limited work hours to protect them from engaging in unhealthy practices, which also protect patients from workload-related medical errors. Some practitioners reduce their workloads, stop taking call, or replace clinical activities with administrative duties. Others pursue teaching, research, or leadership. A few might change career paths altogether. One colleague of mine abandoned work in the ICU to become a palliative care physician. “I still help people survive,” he said, “but for different reasons.” Such transitions are not failures. They are adaptive responses to changing realities.

Reinvention, however, is more deliberate. It requires acknowledging that personal identity can be ever-changing. Searching for meaning or purpose is laudable and healthy, so long as one knows that meaning and purpose may change, and that to preserve meaning, one may need to redefine purpose. Healing can take many forms.

The accelerating presence of artificial intelligence adds another element to the profession’s landscape. As algorithms assist with diagnosis, documentation, treatment plans, and pattern recognition, many traditional markers of expertise will shift. Physicians will need to learn how to supervise and interpret AI systems, and at times override them. Some professionals may find aspects of their work replaced by machines.

There is no doubt, however, that the physician’s role will endure. Transition will require deeper critical thinking, discernment about how information is used, judgment about when to act and when to practice restraint, and the capacity to navigate ethical tensions and the often-unpredictable nature of human interactions. What ultimately remains is moral presence.

Professional identities may need to be reconfigured. Personal identities will endure, not by resisting change but by embracing it thoughtfully and with consideration.

In this sense, the physician’s journey, like that of a river, is ever-changing. Yet the vocation itself remains one of healing.

· Offri D. What Physicians Feel. Beacon Press, 2013.

· Maslach C., and Leiter M. The truth about burnout. Jossey-Bass, 1997.

· Hollis J. The Middle Passage: From Misery to Meaning. Inner City Books, 1993.

· Ethical AI use in Medicine: A Clinical Practice Toolkit. AMA Published online, December 19, 2025

· Graham DW. Heraclitus. Stanford Encyclopedia of Philosophy, 2023. https://plato.stanford.edu/archives/win2023/entries/heraclitus/

Let’s be truthful about it: today, almost anyone can claim to be a mentor. The traditional boundaries between mentor and mentee have thinned, if not dissolved altogether. The old hierarchies have been disrupted. Technological advances have made knowledge instantly accessible. Experience is archived. Artificial intelligence delivers answers and explanations that once took days and even weeks at a mentor’s elbow to acquire.

We live like fish in a glass bowl, observed from every angle by anyone who takes the time to explore our social media presence. Our credentials, our lectures, our opinions, and often our errors are searchable. Advice flows freely. Influencers influence and teachers teach, often with a degree of polish and expertise not always attainable at the workplace itself. They say power is proximity — but not today, not when it comes to knowledge.

And yet something essential remains unchanged.

In medicine, we are trained to think vertically. Authority descends from senior to junior physicians, to trainees, and students. In earlier eras, students spent hours in the library photocopying articles for their supervisors. Interns memorized patient details to demonstrate loyalty and competence. Residents listened carefully and spoke cautiously to their superiors. The opinions of the most experienced physician, or the most eloquent during rounds and conferences, carried decisive weight. Knowledge and power were closely aligned, and few openly questioned either.

Today, that alignment is less secure. A resident’s question can unsettle a senior physician’s habit formed decades earlier. A student equipped with the latest data and less encumbered by tradition may challenge longstanding practices. A nurse may ask for justification before carrying out an order. Questions come faster. Scientific evidence is demanded more quickly. Uncertainty is less tolerated. Authority must explain itself in real time.

The shift can feel destabilizing. I have felt it myself.

There is almost always a subtle discomfort in being corrected or even taught by someone younger. There is vulnerability in realizing that the evidence has already evolved beyond our most recent literature search. The flattening of a traditional hierarchy is uncomfortable, not only because it exposes knowledge gaps, but because it exposes temperament. How we respond matters almost as much as whether we are correct.

In these moments, lessons travel upward.

In social theory, this dynamic is often called reverse mentoring. It is particularly dominant in business and information technology, where younger professionals may be most adept with the latest technologies. It is also an element of family life, when a child patiently (and sometimes impatiently) reprograms a parent’s cell phone. In medicine and medical education, reverse mentoring defines learning as a reciprocal, two-way exchange of knowledge that sharpens the judgment, performance, and understanding of both participants and extends to all members of a multidisciplinary health care team.

There was a time when experience alone secured influence and control. Today, experience coexists with transparency, and authority is scrutinized, often publicly. Where mentorship was once private and top-down, now anyone can be a mentor.

What remains unchanged is responsibility.

Even when a mentee appears to be speaking truth to power, even when traditional authority is questioned, and knowledge is dangerously democratized, the underlying dynamic in medicine remains oriented to the same end: the patient’s welfare. A shared commitment to do good anchors the relationship. It steadies the exchange and tempers the ego when we allow it to.

Technology and the democratization of knowledge may have altered the architecture, but they have not altered the weight of critical decision-making. That weight still rests very much on human shoulders and on person-to-person judgment.

Anyone can be a mentor.

But only those willing to be examined in full view can remain one.

· Clarke AJ, Burgess A, van Diggele C, et al. The role of reverse mentoring in medical education: current insights. Adv Med Educ Pract 2019;10:693-701.

Lysfjord EM, Skarstein S. Empowering Leadership: A Journey of Growth and Insight Through a Mentoring Program for Nurses in Leadership Positions. J Healthc Leadersh 2024;16:443-454.