Part I: Subjective
“My daughter! My daughter called me today!”
“I’m so glad to hear that. It must be great to have such wonderful children.”
“Her love is shining through… she… she said she wants me to stay with her…”
* * *
Every presentation is supposed to tell a story, or so my attending says. But what story begins with a one-liner? It feels less like an enthralling tale, one which delicately unfurls and sprawls across mountaintops, and more like open mic night.
The setups are strikingly similar. When delivering a presentation or stand-up routine, the message must be crystal-clear. It must be punchy and succinct, and include ear-raising inflections and flashy gestures to nurse your audience’s dwindling attention. It must be meticulously crafted, rehearsed, and tweaked so as to elicit the right reactions at exactly the right times. It also helps to crush a Coors Light beforehand, but that won’t fly except on the most traditional of services.
More than just stand-up, humor permeates medicine. Sometimes, it is shared with patients. Other times, it is tossed around a work room. Some things are only funny in retrospect. Humor is a coping mechanism, and in medicine, it is almost universally used.
If humor is born from subversion, then even complexity itself can be humor. From that perspective, the study of internal medicine should be hilarious. I certainly have found myself squeezing out a few laughs whenever I have to meticulously relearn six medical conditions for a new 6 p.m. admission, or guffawed while standing in front of a patient and realizing that I have no idea where to listen for each of the murmurs. Or maybe those were actually the weak and desperate laughters of exhaustion. Either way.
What is most striking to me in medicine is the blinding contrast between comedy and utter sincerity. I have witnessed the amazing joy of a mother, budding out from delirium, as her daughter makes her way from out behind the care team; the bittersweet smile of someone without a family receiving roses and speckled azaleas; and the final thank-you of a nature-lover, cured, heading back to his self-made homestead to fish his days away.
These are all beautiful things. You may find it distasteful that they are marred by backroom gags and wisecracks, and perhaps you are right. It is terribly hard to know where to draw the line, to discern what you should act on or speak up about. The more jaded your team is, the more likely you are to hear some potentially uncomfortable zingers. However, in the right formulations and dosages, humor can uniquely lighten the most dark, depressing, and morbid moments on a service. Humor is both surgical and extremely subjective, so the best jokes titrate with taste. It is a powerful, angled tool to be held responsibly, and the line between hurting and healing is razor-thin.
I was fascinated. I remember boiling in my seat in that dingy workroom, a fresh-footed recruit on the cusp of my first ever clerkship rotation: internal medicine. As rounds begin, I am a fly on the wall, a confused fly, attempting to piece together the continuum of clinical language in a few short hours. I fail, but whenever I manage to pick up on something that I actually understand (read: something funny), my ears perk up like Marmaduke and I tab out to quickly jot down the phrase on a virtual sticky note. Yes. Another shining pearl of comedy to be studied.
Then, on rare days when I get out while the sun is still up, I head to a café, pull out my laptop, and skim through my Spotify library, populated by cutting-edge releases and reminders of an era when I was a little too into Elvis Costello. I am sitting next to a man wearing a jean jacket who is swiping between desktops on his glimmering MacBook Pro. He is entering commands into a console, altering counter values, missing commands, traversing spreadsheets, monitoring outputs, and occasionally flicking back left to tweak his algorithm. He has ChatGPT open and at the ready, and he also has an iPad for some reason.
I am on uWorld, but still I wonder — what is his world like? Likely also filled with mirth, with tell-alls about racy colleagues and rogue corporations and the movers and shakers of big tech shared giddily over oyster shooters and yellowtail jalapeño. I sip my coffee and then consider the hospital cheeseburger I plan to buy for tomorrow’s lunch break, which will be genuinely relished. I consider that this coffee shop, this conduit of professional labor, is united by humor, yet divided by its own darkly comical and absurd contrasts: between fluffy crust and raw cud, flying blood and GitHub. Why am I me and why is he him? What separates us, apart from market forces and personal convenience? A more profound reason than that seems obscure, laughably unobtainable, but before I can finish the thought — I pick the 2% answer on uWorld and become inexplicably sad.
The dimly-lit way home is littered with crumpled paper cups and soggy newspaper shreddings. Next to a random alley, I am again struck by it all, and I exhale briskly through my nose. It’s all going to be alright.
My introduction to medical practice comprises a series of curious translocations. I was an over-eager, yet cautious, greenhorn from a sleepy town, and when I would finally charge ahead with zeal, I would crash, repeatedly and spectacularly, shattering experiences across sites, teams, and patients. Just as it had graciously buoyed me back then, now humor offers me the precious chance to recollect.
Part II: Objective
“Either I get my coffee or I call out sick.”
“Speak for yourself, I’m decompensating over here. I haven’t been off in weeks.”
“No way.”
“…you ever think about if we went back in time and chose different careers?”
“Ha!”
“All the time.”
* * *
The Pavilion is a 1.5-million-square-foot, 17-story facility with 47 operating rooms and over 500 private patient rooms. It opened its doors in 2021 after years of planning and construction. Towering, penny-bronze, and future-ready, the structure boasts a reimagined two-floor emergency department, an advanced epilepsy monitoring unit, and a fully-equipped human neurophysiology lab. Each patient room features IRIS, a 75-inch screen and smart board which lets patients seamlessly review their imaging results and customize the environment to their tastes, placing control over temperature, lighting, and window shades mere taps away. The total cost of the project was $1.6 billion.
I can see the Pavilion through the window of the Founders 14 work room, which is a repurposed family waiting room, or to be more accurate, an oversized broom closet with stiff chairs and a couple of rolly computers. One of the keyboards is broken today. Try as we might, we cannot get it to work because the port into which it plugs, along with the rest of the machine’s internals — the hard drive, the memory, and the central processing unit, which are themselves encapsulated very nicely and very safely by factory-issue plastic — are themselves trapped, locked within a smooth metal chassis only breachable by a quick-witted, sun-spotted, key-wielding man who has roamed the halls of old HUP since the fall of black-and-green terminals. So today I am using my laptop.
I don’t have a desk — more specifically, there are no desks in the room, just knee-high side tables — but I make it work. I start typing feverishly in a tiny Epic box, flipping between UpToDate tabs and walking down Penn Pathways, incorporating everything that is objective and good and true into my humble progress note. I hunch, creating a world of back problems for myself 30 years down the line, and lean further still into this note. I look it over, and then I check it again, and then one more time. Pertinent labs and results: recorded and interpreted. All active problems: addressed and accounted for. Subjective: illustrated, beautifully. I hit “pend,” take a swig of meal replacement, and then chase it down with some unfortunate coffee. Time for rounds.
Rounds begin, and my attention already begins to fade. I look through the wide window of the work room and try to find Presby, but I can’t. For that, I realize that I have to look into the past.
It is already 9:00 A.M. on some sunless weekday. We all fit into a cramped, dim room and surround a man who is conscious but cannot move. It is time to change the sheets. Nurses move in and out, their passing chatter revealing inadequate equipment and scant manpower. No worries, no worries at all. We are here to help. We don our masks and gloves and the nurse, the undisputed head of the operation, is explaining what to do, gesturing to each of us which parts of the crusted sheet to grab, which body parts to stabilize, and emphasizing the speed at which all of this must occur. The clean sheets, albeit crumpled and antique, are prepped and ready to fly on the second top brass issues the command.
It’s a wonderful choreography. We use all our might to prop up his side, then lift, then roll, and now his arm is coming over, and now we reposition our hands, and dig in, and brace, and push, and follow through. The intern snatches up the soiled sheets, sending up motes of dead skin which dot the air like golden snow. “Still doing alright?” “Hang in there, we’re almost done!” The man — groaning in pain — is now balanced on his side, allowing four of us to release pressure. Immediately, one corner is hooked on. Then two. (I take three.) Four corners on, now pull. Pull!
The man tips over and settles deeply in his new bed, peaceful again. I carefully remove my gloves, pungent and slick with sweat, and follow the rest of the team out of the room into a hazy fluorescent hallway. I pull down my mask and begin to breathe again. I swivel my head to scan the crowded emergency department of the number one teaching hospital in Pennsylvania for some sort of acknowledgement, a weak smirk, a knowing look, anything, that confirms that I just did that, that the undertaking really just happened, but I am alone. My team has moved on to the next patient, and now so must I.
Part III: Assessment
“It’s a real shame.”
“Yeah. Well, this is what they call the ‘Good Family Sign.’”
“What’s that?”
“The nicest people with the kindest families get the worst outcomes.”
* * *
The practice of medicine is inherently existential. When faced with illness and death in the wards every single day, interrogating mortality becomes less of the rare thought in the bathroom mirror at 3 am and more of a persistent fixture of life. Even as a bright-eyed student-doctor, I have already noticed the changes. My ruminations can be boiled down to three essential questions: 1) why am I here, 2) why am I doing this of all things, and 3) am I happy? I am sure I am not the only one who has wrestled with these questions. In fact, try as humanity might, I contend that these questions have remained unchallenged for eons.
Enter artificial intelligence. AI models have wormed their way into every conceivable industry, profession, and echelon of academia. Physicians will not be spared by this rise, and they will be forced to continuously reevaluate their role in their profession as AI encroaches on their duties. This isn’t just conjecture — last year, Epic rolled out a new AI tool that can listen to a conversation between a patient and doctor, pick out the pertinent details, and auto-generate progress notes. Preliminary reports have shown hours of saved time for doctors and marked increases in note quality, making it clear that the so-called revolution is real and already here. If an intelligent algorithm can parse patient data, form clinical diagnoses, and prescribe medications with a lower error rate, fewer poor outcomes, and in less time than human clinicians, then we would be morally remiss to not incorporate AI into our healthcare systems.
This sounds like great news. Physician burnout has plagued the profession for decades, and it has only been exacerbated by the adoption of the electronic medical record. If AI can handle all of the tedious billing and documentation, then physicians will finally be empowered to focus on the more fulfilling, “human” side of medicine. Right?
But what exactly is the “human” side? How far are we willing to take AI? How much reliance is too much, and is there a limit? The answer to these questions will ultimately be personal. In practice, however, the answer will unfortunately be driven by mass convenience and capital. The doctor who values human interaction may very well be phased out by the AI console which can seamlessly (and politely) relay care plans to patients in a way expertly titrated to their cultural and socioeconomic backgrounds. When personal fulfillment is at odds with societal forces which whip relentlessly across the heavens, what is there to do? My solution is to bear down. I grit my teeth, weather the storm, and seek internal peace. I am a rock, and at least for now, I can hold out. For now, the winds are still calm.
But this conversation extends far past medicine. Gone are the days of healthcare workers bearing the brunt of existential philosophy and morbid reality. With robotics and the concept of artificial general intelligence threatening to replace all possible human functions and capabilities in the near future, everyone will soon have to face nihilism head-on. If AI can digest any corpus of text to “learn” it, successfully drawing new connections and solving problems with professional-level expertise, then what is the point in developing critical thinking or learning anything? If advanced robotics and an intelligent control algorithm can do everything from warehouse work to surgery with minimal supervision, then what is the point of developing hand skills or spatial awareness? In a media landscape where AI models can generate beautiful, evocative, human-quality text, imagery, and sound for any conceivable purpose at blistering speed, what is the point in pursuing art?
We are barrelling toward an era in which we will have no choice but to create a completely simulated environment for ourselves, both online and in the physical spaces we inhabit. It will simply be the moral thing to do. Soon, our environment will be fully-customizable, lightning-fast, safe, predictable, and profitable. It will be built for pure, unbridled entertainment. There will no longer be workplaces, because we will work from our own AI-optimized homes, and any work we do (or art we create) will be quaint, a gesture of the past acted out for mere personal enjoyment — everything important will be handled by the computer. The media we will consume day and night will be driven by content creators using AI to tantalize the widest possible audience, who will then consume what they are presented uncritically, not just because they are unable to distinguish reality from simulation anymore, but because they will be getting exactly what they want. The concept of art will be fundamentally reversed: art used to be an author’s ideas carefully distilled for an audience’s consumption, but soon it will be an audience’s own ideas, reconfigured by the model and slated for endless self-consumption. Our assessments and preferences will be guided not by validity or merit, but only by shallow aesthetics and cultural assumptions: what do we think a food review should look like, or a prank video, or a romance novel? Say the word, pay the price, and it’s yours.
If we continue at our current rate (which we almost certainly will), there will come a point where humans will no longer have to do, create, or learn. The only things left will be that which a circuit board cannot accomplish: consume, feel, and perceive. With AI, we are spiraling toward a mass culture that is paradoxically insular, infinitely teleological, and ultra-personalized to each individual’s own taste and understanding, a stagnant world in which everything you read, see, or hear is generated to be “useful.” Statistical hallucinations will become inseparable from what is real, and finally, the concept of the author will be laid to rest.
A man, in pain, lies on a bed. A dingy light illuminates the tiles surrounding him, below and above. He has been there more days than he can count. I open the door, apprehensive as always, but I force myself to relax. As I approach the bed, I feel out the room in split-second saccades: the window, a woman, a chair, some flowers, stained sheets, extra pillows, hospital pamphlets, plastic cups, nutritional shakes, cranberry juice, pill bottles, long plastic tubes, flashing screens, a nasal cannula. Then, the face. Exhausted, sweaty, struggling to breathe.
I deliver my daily report to both parties, and his wife perks up ever so slightly as I relay the plan. Then the exam, less methodical than how I was taught, proceeds with touches, taps, a swinging stethoscope, and pressing palms. No change, no delta. Everything looks good, sir. He bows his head and shuts his eyes.
I encode the findings in my mind and start to peel off my gloves, but a sharp twinge from within stops me before I turn around. Slowly, I drop down next to his bed and place my hand on his shoulder. “It was so nice to see you this morning.” His lips, cracked and stained with dried blood, quiver for a second. Then, for the first time that week, they form into a smile. “Thanks, Ian.”
The weekend passes, and I am trekking back to the hospital yet again. I return to the work room, take my station, sign into Carelign, and boot up Epic. As usual. As I wait, the intern subtly flags me down and whispers, “Did you see the update?”
I immediately open up his chart. I see the trends of his vital signs, large and center, rapidly curving into the earth. A small pause. I put the rest of my tasks on hold and hover my mouse over the last measurement. Zero, zero, zero, zero over zero, zero percent. My eyes dart toward the problem list, and the room with the dingy light flashes back into my brain. I move my mouse, change the tab, and reveal the most recent notes. I find and open the discharge summary, highlighted in bold red letters. Is it still a discharge if the patient never left the hospital, and never will? As I read the summary of the hospital course, my eyes catch on every little detail, every blood product administered without improvement, every emergency procedure tried and failed, every stabilizing medication maxed out and exhausted. Finally, a short conclusion and the parting phrase of professionals: “It was an honor for the team to be part of this patient’s care.” I notice my attending sitting across the room. Through a dizzying, white, bloodless haze, I see him turn to me, and his mouth moves to tell me it was all very unfortunate.
When the time comes for me to relinquish my role to AI, I wonder: will I be proud of how I’ve spent my time?
Part IV: Plan
“What’s the word? ‘Aspire’…?”
“Yeah, exactly!”
“You know, I wanted to do so much when I was young. I wanted to be a nurse, but my mother said all that biology was too hard for me. She said I couldn’t handle it. My older brother and sister, they did well for themselves. One was a judge and one was an accountant, but I never made much of my life…”
“Oh, don’t say that! I’m sure that’s not true. And anyways, what’s important in life is your own happiness.”
“Maybe… maybe. I don’t know, Ian. It’s a feeling I don’t really understand.”
“I’m sorry to hear that.”
“It’s okay. It’s okay, because you know what? I’m not a nobody. I’m not a nobody because I am proud of you. Remember that.”
* * *
When I finally returned home after months of being away, my bedroom was infested with carpet beetles. “Sorry, no one goes in there when you’re not here,” my mom said. My sister shrugged and said, “Hey, it’s not my fault they laid eggs in your carpet.” My dad was at work, as usual. The dogs howled.
The carpet is white, red, blue, and green, about six feet long and five feet wide, rectangular with a patchwork pattern, and plastered all over with dyed-on sailboats, although I really was more of a train kid. I crouched, straining my heavy eyes to inspect the carpet’s surface. I saw nothing but scattered signs of wear, as if small chunks of fabric had been scooped out of the carpet like curettes into flesh, but these were of little concern; the holes had been there as long as I could remember.
As idle, sunny days spent lying on the floor replayed in my head, a small bug suddenly crept out of the wooly fronds and into view. It was an elegant little thing, slender and unassuming, pale and tan like an old leaf. It continued to traipse about, into and around dense, fleecy peaks. All I could do was watch. Then, my eyes picked up another flicker — another bug. Then another. And another. Then one right next to my foot. I immediately stood up and shuffled back. The tiny bugs, I realized with horror, were everywhere. I peered into the chronic wounds of my childhood carpet, and as I looked even closer, recognized that now they were different. Each hole was lined by sinister mounds of miniscule, gritty, sand-like orbs which stuck stubbornly to the sides and extended deep into the threads. I instantly felt sick to my stomach. Copious pours of vinegar, a mop, and a groaning teenage girl were all I needed to roll up my old friend and pitch it out the front door.
When I finally returned home after months of being away, I showed my sister the passage I wrote above and she said, “Why did you make me sound so snarky? I mean, it still isn’t my fault though.” My mom, bundled up in her shiny golden blanket from Temu, had no comment and instantly tried to show me a Facebook video featuring a meerkat. My dad was in the middle of a shower, as usual. The dogs snored.
Some things never change. And yet, we grow. The years slip away while we get caught up in the everyday. I find that self-reflection is my salve for the sorrow of time, and it is crucial. Also important: art. In particular, I prefer music and writing — in my free time, I write, make music, listen to music, and read (hey, poems and crosswords count!) — but when I say “art,” I mean it in a broad sense. Art is anything that is an object of attention. An affective source, expansive and exhaustive. Art is what is self-contained and still spirals endlessly outwards. Art dreams, and meets you halfway. It says nothing. It is everything. Art is self-referential. Art is intrinsically satirical. Art is jagged, and it is contradictory. Art is forlorn, passionate, and defiantly meek. It tears violently at the seams of custom. Art is pretentious, oh yes, pretentious, because the creation of “art” itself implies a degree of self-importance that no one can truly possess. The type of art that shakes me to my core is embarrassing and trite and encyclopedic and arbitrary and not a single lick self-aware. It leans boldly into its own artificiality, its own forgery. When I write, I keep these lofty criteria in mind, but — alas! — interpretations are perilous and prying eyes are ever toxic. I have found it’s like trying to snap your fingers with your left hand; no matter how hard you try, it never comes out quite right.
So, maybe I have it all wrong here. Maybe it’s all kerfuffled, and discombobulated, and backwards, and maybe I should start all over again from the beginning, and maybe my meticulous drafts were made in error, and maybe my philosophy and worldview are dumb, and maybe that “Presby and the Pavilion” allegory earlier was way too heavy-handed, and maybe things don’t even flow too well, and there’s too much fluff, and it’s all collapsing underneath its own weight, and maybe I should have GPTed this, and geez, maybe I should have invested in crypto and Apple and the foreign exchange market after all, and maybe that one realtor was right about medicine and careers in general, and maybe, just maybe, this hackneyed idea for an essay was nothing more than a sad dud, a complete non-starter.
That may all be true. And yet, I write.
I write and I practice, truly practice, medicine. I hold my chin up and present myself in the way I see fit. I think of my patients, and I think about the flying carpet beetles, and about their sandy eggs, and I think about the afflicted tubular affair rotting on the front lawn, and I think about how temporary our time is here. So, I share my experiences alongside precious pieces of myself. I laugh, really laugh, and breathe in the quippy ephemera of the day. I explode in textual collage. I set free the quotes that hang caged in my head.
If you believe in your art, that something is truly great, then you can do no wrong. For me, the perfect art is funny, desperately so, and composed of interlocking loops of discourse: with society, it is bitterly reflective, with other people, it is earnest, and within itself, it is fragmented and self-defeating. Such art reflects the human condition, my bizarre thoughts, and my multithreaded being to the utmost. In an increasingly automated and standardized world, staking your claim to something complex (and even hated for its complexity) is revolutionary. The author name at the top of the page is a symbol which says that I conceived of this, that I wrote this, that I was here. This is my authentic self. This is my presentation without compromise. A standardized patient once told me that I need to focus on exuding more confidence and that a “sense of tenuousness” permeated the entire visit. Well, who’s confident now?
I hear it again. I hear the attending finally chide: “Get to the point.” Of course, of course. Where does all of this meandering and musing take us? What is the application, the meat, the moral? Within sleepless nights, numbing sacrifices, and unimaginably recursive bureaucratic drudgery — what is the point?
My friends, it is simple. The point is what pierces skin and enters flesh. It is what is guided by ultrasound and held in by Tegaderm. It injects and invades. It spikes emotion. Often the point is feared, by patients and medical students alike, and other times, it generates nothing but sleepy ambivalence. “Do what you have to do, I suppose.” The point can be obscure, mass-produced, or fluctuant — it lies somewhere between pragmatism, the here-and-now, and existentialism. The point is the future. It is a finger which extends boldly forward into the unknown. It is the compass needle which stays true no matter what. It is inner resonance, and the perfect, sharp end of a heart. It is the crisp air which brings your body peace. That is the point. And when the all-important time finally comes, I hope you will find your own way to wield it with grace.
Do you have any questions?
Ian Ong is an MS2 at the Perelman School of Medicine.
