An embryologist who wants to know which part of an early embryo will become skin, and which will become gut, can find out by marking a small patch of cells and waiting. In 1929 Walther Vogt did it with dye. He let a stain that living cells can tolerate dry into small chips of agar, pressed the chips against chosen places on the surface of an amphibian embryo, and followed the coloured patches as the embryo folded itself into the shape of a tadpole. Today the marks are fluorescent, or are written into the cells’ own genes, so that every descendant of a labelled cell carries the label with it. The principle has not changed. Mark, wait, and look. Mark enough patches and you can draw a map of the early embryo on which every region bears the name of what it will become. Biologists call it a fate map.
It is a beautiful document, and developmental biology has been unusually careful about the way in which it can deceive. A fate map records what cells normally become when nobody interferes with them. It does not record what they could have become. The map is drawn by watching the undisturbed case, and the undisturbed case is precisely the one that hides the alternatives. Once the animal is grown and every arrow on the map points to the right tissue, the map begins to look less like a record and more like a decree.
That is the difficulty with writing about 1995. That year I was in the middle of my pre-medical studies at Khalsa College in Amritsar, which ran from 1994 to 1996. The MBBS at Sri Guru Ram Das Institute of Medical Sciences and Research, from 1997 to 2002, still lay ahead, and behind it the residency years in Little Rock and Fresno, and behind those the practice of medicine in California since 2010. Read from 2026, the sequence is a fate map. Every patch is labelled. Every arrow points toward medicine. The biology student turns up, as reliably as a stained cell in a grown frog, in the physician.
What the map cannot tell me is how determined he was.
I would like to answer that honestly, and I am not certain I can. This essay is an attempt to say why, and to say what an honest answer would have to include. It borrows words from embryology, from the psychology of memory and from the reading of old clinical records, because each of those fields has had to learn, in its own way and at its own cost, the difference between what happened and what had to happen.
Specified, Not Yet Determined #
Developmental biology keeps separate words for the stages of a cell’s commitment, and the separation is the point. A cell is said to be specified when, left to itself, it will follow its usual path, but can still be redirected if its circumstances change. It is determined when its course can no longer be reversed: moved to a new place, surrounded by new neighbours, it keeps to the path it was already on. The difference cannot be seen by looking. It has to be found by disturbance. The classic test is surgical: lift a patch of cells from one part of an embryo, set it down among strangers, and see whether it becomes what the old neighbourhood expected or what the new one asks of it.
The answer depends on the organism and the hour. In some embryos many cells are set early, by materials parcelled out unevenly in the egg before it ever divides; biologists call this autonomous specification. In others, a great deal is decided by conversation, by signals passing between neighbouring cells, and a transplanted patch can be talked into a new identity; this is conditional specification. Most real embryos use both, and the same tissue may be open to persuasion at one stage and deaf to it a few hours later. There is no single rule, and the textbooks are careful not to pretend otherwise.
What interests me is the asymmetry between the two kinds of knowledge. Fate is learned by watching. Potency, the range of what a cell could still become, is learned only by interfering. A map made by patient observation will tell you, with great precision, where the cells went. It will tell you nothing about where else they might have gone. For that you need the second experiment, the one in which you move them.
In a human life the second experiment cannot be run. No one can lift the student of 1995 out of Khalsa College, set him down among different neighbours, and see what he would have become. The only evidence is the undisturbed case, the life that actually happened, and that is exactly the evidence least able to answer the question.
I should be plain about the limits of the borrowing. These are words for cells in embryos, and a student is not a cell. A metaphor carries no evidence across the border with it; it cannot prove that a person was or was not committed to a path. What it can do is keep a distinction in view that ordinary speech tends to blur. In English the word fate does two jobs at once. It can mean what happened, and it can mean what was bound to happen, and we slide from the first meaning to the second without noticing.
Punjabi blurs the same line in its own way. ਲੇਖ, lekh, is the ordinary word for a piece of writing, an essay or an article. In everyday speech it is also the writing of fate, the lines said to be written on a person’s forehead, ਮੱਥੇ ਦੇ ਲੇਖ, matthe de lekh. In the idiom the writing comes first and the life follows it. The embryologist’s map reverses the order. The life comes first, and the writing is done afterward, by someone who was watching. That reversal is the one to keep in mind whenever a finished career is used to read an unfinished year.
The Year in Its Own Tense #
In a journal entry of 1843 Søren Kierkegaard granted the philosophers their point, that life must be understood backwards. Then he added the proposition they forget: that it must be lived forwards. He did not stop there. Thought through, he wrote, the second proposition ends by showing that life in time never becomes properly understandable at all, because at no moment does one reach the stillness from which to take the backward view. The sentence is usually quoted as a consolation. In the journal it reads more like a warning. The backward view is the only one in which life makes sense, and it is never available to the person living.
A year at college was lived forwards, at the speed of a day. Its horizon was short. A student’s future is mostly the next chapter, the next practical, the next examination, and only occasionally, and usually at night, the shape of a career. The present had its own business, and the business was not medicine. It was physics, chemistry and biology, at the level those subjects are taught before any professional training begins: the classification of living things, the structure of cells and tissues, the parts of plants and animals, the labelled diagram drawn and redrawn until the hand knows the shape. Biology at that level is mostly a long apprenticeship in looking. Very little of it announces its use. Some of it would matter to medicine directly, some indirectly, and some, as far as I can tell, not at all, which is not a criticism of it. A subject can be worth a year of attention without ever being cashed in.
That much I can state with confidence, because it is the public outline of a pre-medical course, and because the outline of my own years is public too: Khalsa College, 1994 to 1996, pre-medical sciences. What I cannot honestly supply is the inner weather of the year. How sure was the student of where he was going? What did he fear? Was medicine, for him, a decision, a hope, a family expectation, a default, or some mixture that shifted from month to month? I can produce answers to those questions. They arrive readily, and they arrive in good order. That is the reason not to trust them.
The present tense of a year deserves a defence, because it is the first thing a finished life takes away. Once the outcome is known, every earlier month is quietly converted into a prologue. Its worries become foreshadowing; its accidents become steps; its uncertainty becomes a kind of charming ignorance that the reader, who knows how things turned out, can afford to smile at. The conversion is almost irresistible, and it is unfair. The student was not living a prologue. He was living the only year he had, with the ending out of sight, and the uncertainty he felt, whatever its degree, was an accurate response to his situation. It was not a misunderstanding waiting to be corrected by the future.
English has a construction built for exactly this conversion, and biographers are fond of it. It is the future in the past: he would go on to, she would later write, the college would become. The sentence stands in the past and reaches into a future that, for the person inside the sentence, did not yet exist. It is a legitimate tense, and an essay like this one cannot do without it. But it does in grammar what the fate map does in embryology. It labels the early patch with the name of the later tissue, and does it so smoothly that the reader stops noticing that the label was applied afterward. In 1995 he was studying biology at Khalsa College; he would become a physician. Both clauses are true. The second has no business in the first one’s year. A student in 1995 could only have said I will, or I hope to, or I might, and the difference among those three is exactly what the biographer’s would erases.
Memory Draws the Arrows #
There is a better reason than modesty to distrust the readiness with which answers about 1995 arrive. Psychology has documented it with some care.
In 1999 the memory researcher Daniel Schacter gathered the characteristic failures of human memory into seven categories, which he called its sins. One of them is bias: the distorting influence of what we now know, believe and feel on what we recall of the past. Within that category he described a consistency bias, the tendency of people’s recollections to exaggerate the consistency between their past and present attitudes, beliefs and feelings. One of his examples was a study by Gregory Markus. People who had rated their views on a range of social issues in 1973 were asked in 1982 to rate them again, and also to recall how they had answered nine years earlier. Their recollections of 1973 matched their 1982 views more closely than they matched what they had actually said in 1973. The past, recalled, had moved toward the present.
A physician remembering himself at the beginning of his studies is exactly the person in whom this tendency would be expected to work. He knows what he became. Memory, rebuilding the student, uses the materials at hand, and the most abundant material is the present. The result is a student who already seems to know where he is going: a physician in waiting, who chose biology because it led to medicine and studied it because medicine required it. The memory feels like evidence. It may be partly the map, drawn back over the landscape in ink.
Schacter also described a second distortion, the mirror image of the first, and it is the one I find more unsettling. The psychologist Michael Ross had argued that the direction of retrospective bias depends on what people believe about themselves. If we assume we have been stable, we overstate the consistency between past and present. If we believe we have changed, we overstate the difference. In a study by Michael Conway and Ross published in 1984, students who took part in a programme to improve their study skills were later asked to recall how good their skills had been before the programme began. They remembered them as worse than they had rated them at the time. A control group on the waiting list showed no such distortion. Memory had made the programme look more effective by quietly lowering the point from which it started.
Put the two findings side by side and the danger for a memoir becomes clear. There are two stories a physician can tell about the student he was, and both flatter the present. In the first, the student was always headed here, and the career is the natural flowering of an early seriousness. In the second, the student was raw, unformed, perhaps a little hopeless, and the profession made a person of him. One story credits the boy; the other credits the training. Each is assembled from the same materials, and each has a strong pull, because each makes the present look like the obvious result of the past. Neither needs to be false in every detail to be false in its shape.
Schacter’s own conclusion is worth keeping, because it guards against turning this into a sermon. He argued that memory’s sins are by-products of features that are, on the whole, adaptive. A memory that rebuilds the past in the light of the present is usually serving the present, which is what memory is for. The bias is not a moral failing. But it does mean that a recollection, however vivid and however sincerely offered, is weak evidence about the specific question of what one intended as a student. A diary, a letter, an application form, anything written in that year and untouched since, would be far better evidence than anything I can now recall. This essay rests on none, and so it says less than memory would like it to say.
A Stone Laid in 1892 #
Institutions keep a longer clock than students, and Khalsa College is a good place to see the difference.
The movement that produced the college began in Amritsar in 1873, when the first Singh Sabha was set up there; a second, in Lahore, followed in 1879. Its programme was in large part educational, and the details are more interesting than the summary. One of the Lahore Sabha’s founders, Bhai Gurmukh Singh, had been instrumental in having Punjabi included in the curriculum of Oriental College, Lahore, in 1877, and became its first lecturer in the language. Schools, presses and a college followed in the same restless decades. The foundation stone of Khalsa College was laid at Amritsar on 5 March 1892 by Sir James Lyall, the Lieutenant-Governor of the Punjab. The main building was designed by Bhai Ram Singh. He came from Rasulpur, near Batala, trained at the Mayo School of Arts in Lahore as a protégé of its principal, John Lockwood Kipling, and worked with Kipling on the design of the Durbar Room at Osborne House, Queen Victoria’s house on the Isle of Wight. Construction of the main building took years; one account dates its start to 1904 and its completion to 1911, and the usual accounts have teaching begin long before the building stood.
When the building did rise it was a composition: an Indo-Saracenic façade in which Mughal, Sikh and British elements are combined, with a dome over the entrance, chhatris along the roofline and arcades of arches on pillars. A building in that manner is designed, among other things, to look as if it had always been there. That is part of its achievement, and it is also a small lesson in how institutions present themselves. More than a hundred and thirty years later, the college’s history reads as a line running from cornerstone to centenary and beyond. In 1892 it was a stone in a field, outside a village whose name was later changed to Kot Khalsa, and a building that the people gathered round the stone could not see. Bhai Gurmukh Singh, who had worked to bring the college into being, died in 1898, years before the main building rose. The founders’ present was as open as any student’s.
Consider one Amritsar life from those same years, read in both directions. In 1891, the year before the foundation stone, a young man born in the city in 1872 matriculated from the Church Mission School there. Read backward, his life looks like the literary destiny of the Singh Sabha itself: he launched the Khalsa Tract Society in 1894 and the weekly Khalsa Samachar in 1899, wrote Sundari and other romances that became forerunners of the Punjabi novel, serialised Rana Surat Singh from 1905, and in old age received the Sahitya Akademi Award in 1955 and the Padma Bhushan in 1956. That is Bhai Vir Singh, and his life has been mapped so often that it is hard to see the matriculate of 1891 at all. Read forward, from 1891, there was no map. There was a young man not yet twenty who had finished school in a city full of new institutions, any of which might or might not last, and a movement whose future was being argued about in meetings, pamphlets and subscription lists.
For a student in 1995 the arithmetic of the institution ran the other way. By then the college had been teaching for more than a century, and each year’s class was, from its point of view, one of a great many: arriving, staying a while, moving on, while the building and the routines remained very much as before. An institution holds its students the way a riverbed holds water. For the student, the year was not one of a hundred. It was the only one he would have there, and it was not repeated. The college’s long clock makes a single year look small and settled. The student’s short clock makes it look large and undecided. Both are accurate. Only the second was available to him at the time.
Waddington’s Landscape #
The developmental biologist C. H. Waddington drew a famous picture for the kind of uncertainty that interests me. He introduced what became known as the epigenetic landscape in his book Organisers and Genes in 1940, where the first illustration of it was a sketch by the painter John Piper of a river spreading into a delta. The best-known version came later, in The Strategy of the Genes in 1957: a ball, standing for a cell, at the top of a slope cut by branching valleys. Near the top the valleys are shallow, and a small push can send the ball into one or another. Further down they deepen, and the ball’s course becomes harder and harder to change. Waddington had a word for the deepening, canalization: the way development, once it has entered a valley, is buffered against disturbance and kept to its course.
There is a second drawing in the same book that I find more interesting than the first. It shows the underside of the landscape. The surface is held in shape by a web of guy ropes attached to pegs in the ground beneath, and the pegs stand for genes, the ropes for the chemical forces the genes exert. Pull on one rope and the slopes above shift. The valleys that the ball rolls through are not simply there; they are held there by tensions that cannot be seen from the surface.
I should not stretch this too far. Waddington was writing about cells and genes, and a picture designed to help biologists think about development is not a theory of how human beings choose their work. A student is not a ball. He can, within limits, climb. Nor is the landscape of a life laid out in advance and waiting to be descended; part of what a student does in a year is to cut it.
Piper’s earlier drawing deserves a second look here, because it is a different picture and for this purpose perhaps a better one. A river entering a delta does not find a single valley waiting for it. It builds the ground it flows across, dropping silt that raises one channel and opens another, so that a map of a delta begins to go out of date almost as soon as it is drawn, and a channel that carried most of the water in one decade may be dry in the next. For Waddington’s later purpose, explaining why development is so stable, the cleaner image of the ball and the valleys was the right choice. For describing a student’s year, the delta may be the truer one: a flow that is shaped by the ground and that, slowly and without intending to, shapes it in return.
But with those cautions in place, Waddington’s pictures, the valleys and the delta alike, are more truthful images of a student’s year than the map. They say, first, that early on more than one valley was available, and they say so without insisting that all of them were equally likely. They say, second, that the depth of a valley is something that develops, and that it develops partly through being travelled. Effort, examinations, the encouragement of teachers and families, the plain momentum of having begun: all of these deepen a course over time, and some of the deepening is done by the traveller. A year at Khalsa College was part of the cutting. It was not yet the canyon. And the drawing of the underside says, third, that the shape of the surface depends on forces underneath it which the traveller may never see clearly: money, the number of seats in a college, the expectations of a household, the timing of an examination, the accidents of health and weather. Some of those forces are personal and some are institutional, and an honest account of a year would need to name the ones that mattered. I cannot name them for 1995 with confidence, and I will not invent them. The image at least reminds me that they existed, and that the smooth valley of a finished career was held in shape by tensions that were never visible on the surface.
Reading the Chart in the Direction It Was Written #
Medicine, it turns out, is full of fate maps, and the habit of distrusting them is one I value more each year.
In 1975 the psychologist Baruch Fischhoff published a set of experiments under a title that is itself an argument: “Hindsight ≠ foresight.” People who were told how a situation had turned out judged that outcome to have been more likely than people who had not been told, and their view of the earlier events shifted to fit what they had learned. Fischhoff called the effect creeping determinism: the tendency, once an outcome is known, to see it as having been relatively inevitable all along. In 1991 Robert Caplan, Karen Posner and Frederick Cheney carried the question into medicine. They gave experienced anaesthesiologists twenty-one case abstracts describing adverse events, each paired with an otherwise identical version in which only the outcome had been changed, from temporary and mild to permanent and severe, or the reverse. The care described was the same. Yet when the outcome was severe, the reviewers were about 30 per cent more likely to judge the same care substandard.
Consider a hypothetical sequence, invented for this essay and describing no real patient. A middle-aged man comes to a clinic with tiredness and a cough that has lingered after a cold. His examination is unremarkable. The physician, reasonably, explains that such coughs often take weeks to settle, and asks him to return if it does not. He returns a month later. The cough is still there, and now he mentions, almost in passing, that he has not felt like eating. The physician orders tests. Some weeks after that a finding arrives that settles a serious diagnosis.
Read backward, from the diagnosis, the first visit looks like the beginning of a clearly marked path. The cough was the first sign, the tiredness the second, the poor appetite the third; surely someone should have seen where they were going. Read forward, in the order the information actually arrived, the first visit contains a common complaint with many harmless explanations, and a plan that was reasonable for it. The second visit contains a change, and the change raised the probability of something more serious, and the question there is whether the response was proportionate to the new information. The decisive fact arrived last, and it arrived for everyone at the same time.
A fair reading has to recover the information that had not yet arrived, and that is harder than it sounds, because the reader now possesses it. Once a diagnosis is known, an early detail seems to have carried a meaning that was in fact assigned to it later. The cough becomes a symptom of the disease, though at the time it was a symptom of almost anything.
This is where the argument against hindsight can go wrong, and the failure deserves its strongest statement. A lesson about hindsight can harden into a blanket defence of every past decision, a reflexive nobody could have known that protects the clinician at the expense of the patient. That is its own bias, and a more comfortable one. Some things could have been known. A warning that was already present in the record and was not acted upon is an assessable failure. So is follow-up that was promised and never arranged, a result that was ordered and never read, or a reassurance expressed with more certainty than the evidence of that afternoon allowed. None of these needs the outcome to be recognised. Each can be identified from the information available at the time, and that is exactly where it should be identified. The outcome is not useless either. It is a reason to look, and sometimes it reveals a fault in the process, a lost result or a broken referral, that would otherwise have stayed invisible. What it cannot do on its own is serve as the verdict.
The same machinery runs in the other direction, and there it is harder to see, because nobody complains. Caplan’s reviewers judged identical care more kindly when the outcome was mild. A good outcome launders the decisions that preceded it. A plan that was careless and lucky looks, afterward, like a plan that was sound; a delay that happened to do no harm is seldom recorded as a delay at all. That is one reason a near miss deserves the same scrutiny as a harm: an event that ended well is the easiest kind to leave unexamined, and the choices that went into it are being made, unremarked, in a great many other cases.
A life story is a long series of good outcomes from the point of view of the person telling it. Everything that led to the present has, by definition, been survived. That is why it is so easy to find wisdom in the choices of a student whose story ended in a profession. The ending launders the year. Whatever in it was hurried, mistaken or merely fortunate now looks like preparation, and the luck that might have gone otherwise is entered in the record as judgement.
So the discipline is a practical one. Read the record in the order it was written. Write down, for each date, what was known and what was not. Ask what action that information supported, and whether the action taken was within the range a careful clinician would have chosen. Only then turn to the last page, and ask what the outcome can teach about the process rather than what it seems to prove about the person. Fairness to the clinician who wrote the earlier notes, and accuracy about what went wrong if anything did, both depend on reading the chart in the direction it was written. They are not competing duties. They are the same duty.
The same discipline applies, at far lower stakes, to the history of a student. Nothing in a pre-medical year needs to be judged, praised or excused by the outcome of a career. But the habit that protects a clinician from being blamed by an outcome also protects a student from being credited by one. If I am not entitled to say that the doctor in the old chart should have foreseen the diagnosis, I am not entitled to say that the student of 1995 foresaw the physician.
A Record of Possibility #
I would not claim that a year of biology taught me any of this. An essay about the dangers of reading backward is the last place to plant a convenient origin, and it would be a small hypocrisy to end by discovering that the whole argument began on a laboratory bench at Khalsa College. It is closer to the truth to say that biology, studied early and returned to over a lifetime, keeps supplying pictures for problems medicine has to think about, and this is one of them: that a description of how things turned out is not a description of how they had to.
What can be recorded about 1995 is less than memory offers and more than nothing. A student was enrolled in the pre-medical sciences at an institution then a little more than a hundred years old, in a building that had itself once been only a stone in a field. He studied physics, chemistry and biology. In 1996 he completed the pre-medical class, and in 1997 he began the MBBS. Those are the labelled patches on the map. Between them lay a year whose inner content, the degree of its certainty, the shape of its hopes, the alternatives weighed or never considered, this essay has declined to reconstruct, because the reconstructions most readily available are the ones least likely to be accurate.
A fair record of that year would contain possibility as a fact about it, not as an ornament. It would allow that effort can be real without certainty, and that commitment can grow without having been complete at the beginning. It would say that the valleys were shallower then than they look now, and that some of their later depth was cut by the walking. It would leave room for the forces under the surface, which a student feels without seeing. And it would refuse both of the flattering stories memory has ready, the one in which the boy always knew and the one in which the profession made him, because each of them takes the outcome and paints it backward over the year.
I do not know whether the student of 1995 was specified or determined, and the honest answer is that the words were never made for him. They were made for cells, by people who knew exactly which experiment would distinguish the two states and were careful not to claim the answer without doing it. That care is the part worth borrowing. The embryologist who wants to know what a cell could have become does not consult the fate map. The cell has to be moved. For a life that experiment is unavailable, and the only honest substitute is restraint: to write the record of a year in the tense in which it was lived, and to let the uncertainty stand where it stood.
This essay is a ਲੇਖ, lekh, in the plainer of the word’s two senses: something written afterward, by someone who was there and is no longer quite the same person. I would like it to stay a lekh in that sense, and not to become, by the slow work of hindsight, a lekh in the other.
Evidence and Editorial Note #
Documented findings. The essay relies on the author’s public biography: pre-medical studies at Khalsa College, Amritsar, 1994–1996; MBBS at Sri Guru Ram Das Institute of Medical Sciences and Research, 1997–2002; residency in Little Rock and Fresno; practice in California since 2010. Walther Vogt’s 1929 use of vital dye on agar chips to mark regions of amphibian embryos, and modern fluorescent and genetic (Cre-lox) labelling: the Embryo Project Encyclopedia, Arizona State University, “Fate Mapping Techniques” and “Fate Map”. The distinction between specified and determined cell states, and between autonomous and conditional specification: the Embryo Project Encyclopedia and standard developmental biology references summarised in the Wikipedia article “Cell fate determination” (which cites Gilbert, Developmental Biology). Kierkegaard’s 1843 journal entry (Journal JJ:167) on understanding backwards and living forwards, and its continuation on life in time never becoming properly understandable: Danish text and translation as given on a source page hosted at the University of Iowa (homepage.divms.uiowa.edu), citing Søren Kierkegaards Skrifter, vol. 18, p. 306; rendered here as paraphrase. Consistency bias, Markus’s 1973–1982 attitude study, Michael Ross’s account of implicit theories of stability and change, Conway and Ross’s 1984 study-skills experiment, and the argument that memory’s “sins” are by-products of adaptive features: Daniel L. Schacter, “The Seven Sins of Memory: Insights From Psychology and Cognitive Neuroscience,” American Psychologist 54(3), 1999, 182–203; Markus’s paper is Political Behavior 8(1), 1986, 21–44. The founding of the Amritsar Singh Sabha (1873) and Lahore Singh Sabha (1879): SikhiWiki, “Singh Sabha”. Bhai Gurmukh Singh’s role in introducing Punjabi at Oriental College, Lahore (1877), and the laying of Khalsa College’s foundation stone on 5 March 1892 by Sir James B. Lyall: the entry “Gurmukh Singh, Bhai (1849–1898)” at learnpunjabi.org, which also gives his dates; the date and Lyall’s role also in The Tribune (Amritsar Plus, 2 November 2006). Bhai Ram Singh’s origin in Rasulpur near Batala, his training under John Lockwood Kipling and his work on the Durbar Room at Osborne House: Wikipedia, “Bhai Ram Singh”, and Dawn, “Architectural stalwart Bhai Ram Singh remembered”. His design of Khalsa College, its Indo-Saracenic style, the dome, chhatris and arches, and construction from 1904 to 1911: “Architecture of Khalsa College Amritsar,” e-content of Government College for Girls, Ludhiana; completion in 1911–12, first classes in 1893 and the village of Kot Sayyad Mehmood later renamed Kot Khalsa: Wikipedia, “Khalsa College, Amritsar”. Bhai Vir Singh’s birth in Amritsar in 1872, matriculation from the Church Mission School in 1891, Khalsa Tract Society (1894), Khalsa Samachar (1899), Sundari (1898), Rana Surat Singh (serialised from 1905), Sahitya Akademi Award (1955) and Padma Bhushan (1956): SikhiWiki, “Bhai Vir Singh”, and The Sikh Encyclopedia. C. H. Waddington’s epigenetic landscape, its first illustration by John Piper in Organisers and Genes (1940), the 1957 version in The Strategy of the Genes with pegs and strings beneath the surface, and canalization: the Embryo Project Encyclopedia, “Epigenetic Landscape”. Baruch Fischhoff, “Hindsight ≠ foresight: The effect of outcome knowledge on judgment under uncertainty,” Journal of Experimental Psychology: Human Perception and Performance 1(3), 1975, 288–299, and “creeping determinism”: as summarised by AHRQ PSNet. Robert A. Caplan, Karen L. Posner and Frederick W. Cheney, “Effect of outcome on physician judgments of appropriateness of care,” JAMA 265(15), 1991, 1957–1960 (21 paired anaesthesia case abstracts; care about 30 per cent more likely to be judged substandard when the outcome was severe): as summarised by AHRQ PSNet. The Punjabi ਲੇਖ (lekh), writing or essay and, in common idiom, the writing of fate (ਮੱਥੇ ਦੇ ਲੇਖ), is stated as general usage. Vendor representations. None.
Recollection and tradition. That the author studied at Khalsa College in 1995 is part of his published biography. No class, laboratory, teacher, classmate, book, mark, ambition, doubt or family circumstance from that year is described; the essay deliberately declines to reconstruct the student’s intentions and states that it rests on no contemporaneous record. The clinical sequence in the section on reading charts is hypothetical, invented to illustrate the argument, and describes no real patient or case.
Analysis and forecast. The use of the fate map, the vocabulary of specification and determination, and the epigenetic landscape as images for a student’s year; the reading of Khalsa College’s architecture; the account of how memory and hindsight affect autobiography; and the proposed method for reading clinical records forward are the author’s interpretation and ethical preference as of November 6, 2026. They are offered as reflection, not as a standard of care or a legal test. Independence. This essay is not sponsored by any institution, company, health system or technology developer. It is personal reflection, not medical advice; readers seeking care should contact their own physician’s office.
About the Author #
Kanwar Partap Singh Gill, MD, traces his family roots to Khadur Sahib in Punjab’s Majha region and grew up in Amritsar. He attended Spring Dale School and completed pre-medical studies at Khalsa College in 1994–1996. He earned his MBBS from Sri Guru Ram Das Institute of Medical Sciences and Research in Amritsar in 2002.
He completed PGY-1 at the University of Arkansas for Medical Sciences in Little Rock in 2007–2008, and PGY-2 and PGY-3 with UCSF Fresno at Community Regional Medical Center from 2008 through 2010. He has practiced medicine in California since 2010.
His career has crossed four distinct information eras: predominantly paper-based medicine, early and fragmented electronic records, the integrated-EHR era, and the emerging age of generative and agentic artificial intelligence.