Written in Amritsar, 03/04/1961 means the third of April 1961. Written in Little Rock, the same eight digits mean the fourth of March. India, like Britain, puts the day first; the United States puts the month first. The two conventions disagree only some of the time, and the arithmetic of when they disagree is worth doing slowly, because it is the arithmetic of a trap.
If the day of the month is thirteen or higher, one of the two readings is impossible. There is no twenty-fifth month, so 25/03 can only be March, and the date corrects itself, provided someone is looking. If the day and the month are the same number, as on the fifth of May or the eleventh of November, the two readings coincide and nothing can go wrong. What remains are the dates on which the day falls between the first and the twelfth and differs from the month: eleven in every month, 132 in every year. A leap year adds nothing to the count, since the twenty-ninth of February cannot be mistaken for anything. On those 132 days a string of digits is a perfectly valid date in both systems and a different date in each. Of the other 233 days of an ordinary year, twelve need no correction and 221 correct themselves, if the reader is awake. The 132 give no sign at all.
In an American hospital that small ambiguity sits near the centre of a ritual. Since 2003 the Joint Commission’s National Patient Safety Goals have asked hospitals to identify patients by at least two identifiers, never the room number, before giving medications or taking blood samples, and the second identifier after the name is very often the date of birth. A doctor trained abroad therefore meets one of the country’s most ordinary conventions inside one of the hospital’s most important safety habits. The two rules arrive together, in the same short string of digits printed on a wristband, and neither stops to explain the other. The hospital assumes that everyone knows which number is the month. The country never thought to mention it.
My own internship was at the University of Arkansas for Medical Sciences in Little Rock, in 2007–2008, and my medical degree is from Sri Guru Ram Das Institute of Medical Sciences and Research in Amritsar. This essay does not reconstruct that year. It describes the problem as any doctor trained in one country and practising in another meets it, partly because the shape of the problem is general and partly because I think it deserves a more exact vocabulary than the word adjustment supplies. Adjustment suggests a single dial turned slowly toward the correct setting. What actually happens is that several different kinds of unfamiliarity arrive at once, dressed alike, and the first task, for the newcomer and for everyone around him, is to tell them apart.
Two Syllabi #
A hospital can name most of what it requires. It runs orientation sessions and certification courses; it keeps policies with numbers and competencies that someone signs off; it has a manual for the order-entry system and a person whose job is to teach it. A diligent newcomer can study all of this and be examined on it. Much of it is tedious, and some of it is excellent, and all of it has the great merit of being written down.
A country, for the most part, cannot name its expectations at all. The philosopher Michael Polanyi put the difficulty in a single sentence in The Tacit Dimension in 1966: “we can know more than we can tell.” People raised inside a set of conventions know them thoroughly and cannot easily list them, because they have never had occasion to notice them. That the first floor is the one you walk in on, and not, in the British usage India keeps, the floor above it. That Medicare and Medicaid, two words that share their first six letters, name programmes with different eligibility, different paperwork and different consequences for what a discharge plan can promise. That a sentence beginning Would you mind is sometimes a request and sometimes an instruction, and that the difference lives in the speaker’s position more than in the grammar. None of this appears in an orientation packet, because nobody who writes orientation packets thinks of it as information. It is the water the packet floats in.
Yet “the country” is itself a convenient fiction, and the essay would be dishonest if it leaned on it. Arkansas is not California. A teaching hospital in one city keeps habits that its counterpart two hundred miles away would find odd, and one ward keeps habits the ward upstairs has never heard of. Within a single service, one senior physician wants a patient presented in strict order from complaint to plan, and another wants the plan first and the story only if she asks for it. There is no single American way of doing most things, any more than there is a single Indian way, and a newcomer who goes looking for the national essence behind every local habit will find a great many essences, most of them imaginary.
So it helps to sort. A doctor trained abroad faces at least four different kinds of unfamiliar thing, and from the inside they feel alike. Some are institutional rules: where a form is filed, which number is paged for which problem, the order in which a particular system wants things entered. These belong to the hospital and may be different across the street. Some are national or regional conventions: the order of a date, the numbering of floors, the names of drugs, the structure of insurance, the idioms of politeness. These, once learned, travel everywhere in the country. Some are individual variations: one person’s preference about presentations or handwriting or the length of a note, which is not a rule at all, however firmly it is stated. And some are matters of clinical knowledge, which travel better than anything else on the list, though not perfectly, since the diseases that are common in one place can be rare in another and the guidelines that govern their treatment are written by different bodies.
Each kind calls for a different response. An institutional rule should be learned and followed, and if it seems wrong, questioned through whatever channel the institution provides. A national convention should be learned once and carried. An individual preference should be accommodated with a light hand and never mistaken for law. A clinical gap should be closed with study and supervision, and until it is closed, nobody should pretend it is something gentler. The difficulty is that a newcomer meeting a lesson for the first time often cannot tell which of the four it belongs to, and the classification decides what he ought to do with it next week, in another hospital, under another supervisor.
Two Thresholds #
Anthropology has an old account of the condition I am describing, though it was worked out for initiation lodges rather than hospitals. Arnold van Gennep’s Les Rites de passage (1909) proposed that ceremonies of transition share a sequence of separation, a marginal period and incorporation, and named the rites of the middle phase after the Latin for threshold, limen. It was Victor Turner, in an essay of 1964 called “Betwixt and Between,” reprinted in The Forest of Symbols in 1967, who looked hardest at the people standing in that middle phase. He described them as structurally invisible: no longer classified, not yet reclassified, often stripped of the signs of rank, expected to be humble and to accept instruction.
Turner also noticed something more interesting. The threshold is where a society teaches what it otherwise takes for granted. In the liminal period, as he described it, the neophytes are shown the culture’s assumptions explicitly, sometimes in grotesque and exaggerated forms, so that they are obliged to think about things they had never had to think about before. Liminality is uncomfortable, and it is also the one position from which a culture’s unspoken rules can be seen as rules.
Internship has the shape of a rite of passage, and medicine has never been shy about its ceremonies. There is a title that arrives before the confidence to carry it, a coat that announces a role, an authority that is real and also provisional, exercised under supervision and checked by someone senior. Every intern is liminal in Turner’s sense. A doctor trained abroad stands on two thresholds at once, the profession’s and the country’s, and they are not crossed on the same schedule. He may already have crossed the professional threshold once, in another country, with its own ceremonies and its own sense of completion, and now he is asked to cross something like it again while also crossing a second threshold that nobody has marked with a ceremony at all.
This is where the anthropological picture becomes a warning. Turner’s neophytes were treated, for the duration of the rite, as if they were blank, ground down so that they could be shaped anew. That may suit a boy in a seclusion lodge. It suits a physician with a completed medical education very badly. An orientation that treats every newcomer as blank wastes what has already arrived and humiliates in the process; an orientation that treats him as already incorporated leaves his real gaps in the dark. The useful course lies between, and it depends on the sorting the previous section proposed. What is clinical and already present should be recognised. What is conventional and absent should be taught plainly, the way a host tells a guest where the light switches are, without implying that the guest has never seen a light switch.
Turner’s other observation deserves to be kept as well. If the threshold is where assumptions become visible, then the newcomer’s confusion is data. It records precisely those places where the institution’s knowledge has become tacit. A hospital that listens to the questions of its newest members learns where its own instructions have gone silent.
What Kind of Question #
A useful orientation begins by asking what kind of question has been raised, and a hypothetical shows why.
Imagine an intern, trained abroad, who has cared for many patients whose hearts were failing and could manage one tonight with skill. On a busy afternoon she is handed a form recording whether a newly admitted patient has an advance directive, and she asks the nearest nurse, Where does this go? The nurse, kindly and at some length, explains why the hospital asks every adult patient about advance directives, what such a document is for, and how important it is to know a patient’s wishes before a crisis. The intern knew all of that. She wanted to know which tray, or which tab in the record. Now reverse it. She asks, Why do we ask this of everyone, even the young man admitted overnight for observation after a fainting spell? and is given, helpfully, the extension of the office that scans forms. Each answer is correct. Each answers a question that was not asked.
Where does this form go? is different from Why is this form needed? The first concerns routing. The second concerns purpose. An explanation that answers one while assuming the other can leave a capable person embarrassed and the actual uncertainty unresolved. If a newcomer understands the clinical decision but not the local mechanism for carrying it out, repeating the medical explanation wastes time and quietly lowers her standing. If the underlying decision is what is unclear, supplying the office number is not enough, and may be dangerous. The next step depends on locating the gap accurately.
The mismatch is not random. Social psychologists call one of its sources the fundamental attribution error, a name Lee Ross gave it in 1977: the habit of explaining other people’s behaviour by their character or capacity rather than their circumstances. A question about a convention is heard as evidence about competence. Someone who asks where a form goes may be suspected of not knowing what it is for, because to a person who has always known where it goes, not knowing seems to require some deeper deficit. The error is understandable and often kindly meant, and it still makes learning harder, because the newcomer begins to ration his questions to protect a reputation he has not had time to build.
He commits the same error about himself, with less excuse, since he holds more of the evidence. Unfamiliarity is easily felt as inability. The feeling of not knowing where the form goes is, in the body, uncomfortably similar to the feeling of not knowing what to do, and a tired person on a long shift does not always stop to tell them apart.
The four kinds of unfamiliarity can also hide inside one another, which is why the sorting matters for patients and not only for pride. A physician from Punjab will have learned the pharmacology of paracetamol thoroughly, including what happens when too much of it is taken. In the United States the same drug is called acetaminophen, and on American medication lists and labels it often appears as APAP, an abbreviation from its chemical name that no Indian textbook would have taught. It is also hidden inside many combination remedies. A newcomer whose knowledge of the drug is complete can therefore fail to recognise it on a list, and so fail to notice that a patient is taking it twice. The gap is not in his medicine. It is in a naming convention, and the consequence of a naming convention can be clinical. Here the categories touch, and the kind of check needed is plain: a habit of looking up every unfamiliar abbreviation, however confident one feels about the subject it belongs to.
Competence, in short, is a profile across tasks, not a single quantity. Joseph Conrad is the great literary example. Born in 1857 to Polish parents in a part of Ukraine then ruled by the Russian Empire, he grew up with Polish, learned French young, went to sea from Marseille in his teens, and began serving on British ships only in 1878, when he was in his twenties and had little English. He passed his examination as a master in the British merchant service in 1886, the same year he became a British subject, and published his first novel, Almayer’s Folly, in 1895. He became one of the great prose writers of English, in his third language, and by many accounts he spoke it with a heavy accent to the end of his life. The literary achievement did not remove the accent, and the accent did not diminish the achievement. They were different tasks, and he was at different points on each.
Newcomers have their own work to do here. Naming the uncertainty precisely can keep a small procedural question from becoming a vague request for rescue. I understand the purpose; I need to confirm how this hospital does it is a more usable question than silent hesitation. It tells the listener which of the two answers is wanted. It also protects, without any special pleading, the knowledge that has already arrived.
The Curriculum Nobody Writes Down #
Education has had a name for the unwritten syllabus since the educational researcher Philip Jackson, in Life in Classrooms in 1968, wrote of a hidden curriculum in schools: the lessons taught not by the lesson plan but by the structure of school life itself, in waiting, in crowds, in praise and in the unequal distribution of power. Medicine borrowed the phrase and made it central. In 1994, in Academic Medicine, Frederic Hafferty and Ronald Franks argued that much of what shapes a physician’s ethics and professional identity is learned outside the formal curriculum, in the habits, structures and assumptions of the institutions where training happens. Courses in ethics, on their account, compete with a much more powerful teacher, which is the conduct of the place.
The paper needs to be read for what it is. It was an argument, a conceptual essay drawing on the sociology of medical education, not a measurement of what any particular school teaches. Its concern was moral: how the culture of training can erode the ideals students bring with them, and why reform of courses alone is unlikely to fix that. It is a lens, and a powerful one, but a lens is not evidence about the scene it is pointed at. To say that a hidden curriculum exists everywhere is not to say what any given hospital’s hidden curriculum contains, and I make no claim here about what any institution I trained in taught or failed to teach.
What the lens does show, when it is turned on the doctor trained abroad, is a stacking problem. Every intern absorbs the profession’s hidden curriculum. The newcomer from abroad absorbs, at the same time, the country’s, which is mostly ethically neutral, a matter of dates and floors and forms of address, but which arrives through the same channels, from the same people, in the same tone of voice. He cannot always tell which curriculum a given lesson belongs to. When a resident is curt with a patient’s relatives late at night, the newcomer has to decide whether he has learned something about how American medicine treats families, or about how this ward runs at three in the morning, or about how this one person behaves when exhausted. Those are three very different lessons, and from a single night the last is usually the safest inference.
Physicians are trained to be suspicious of conclusions drawn from one case, and the newcomer needs that suspicion turned on his own observations. One instance is a case report. It can suggest a pattern, and it cannot establish one. A newcomer who generalises from a single person’s habit to a national norm will learn things that are false, and if he carries them forward, he will teach them in turn: to the next newcomer, or in the stories he tells about the country to people who have never been there. Stereotypes are often made exactly this way, by honest people reasoning from small samples under stress. The remedy is not to stop noticing. It is to hold each lesson provisionally, labelled with its source, until a second and third instance confirm it or the next ward contradicts it.
The stacking also works in reverse. A newcomer brings his own hidden curricula with him, from his medical school and his country, and these are no more visible to him than the new ones are. Some of his habits are excellent and will strike his new colleagues as admirable. Some were local conventions all along, which he took for the nature of medicine because he had never seen it practised any other way. The second threshold reveals those too, and that may be the least comfortable discovery of all.
A Form Is Not a Philosophy #
Sometimes the formal and the tacit meet in a single sheet of paper, and the advance-directive form is the best example. In June 1990 the United States Supreme Court decided Cruzan v. Director, Missouri Department of Health, a case about a young woman in a persistent vegetative state whose family sought to withdraw artificial nutrition. Later the same year Congress passed the Patient Self-Determination Act, widely understood as a response, and it took effect in December 1991. Under it, hospitals that take part in Medicare and Medicaid must give adult patients written information about their rights under state law to make decisions about their medical care, including the right to accept or refuse treatment and to prepare an advance directive. They must record in the patient’s chart whether such a directive exists, and they may not make care conditional on whether a patient has one. The law also asks institutions to educate their staff and their communities.
Around that requirement American hospitals have built a conversation that every intern learns to hold, about what a patient would want if things went badly. It is easy for a newcomer to read the form as a national philosophy written down: Americans believe in individual autonomy, and so they ask. Then it is easy to draw the contrasting picture of home, where, the story goes, families decide. Both halves of that story are too crude to be useful at a bedside.
The law requires asking. It does not require anyone to have an answer, and many Americans never complete an advance directive. American families argue at bedsides, sometimes bitterly, and American law gives family members and other surrogates a large place in decisions when a patient cannot speak. The form is a procedural guarantee, a promise that the question will be put and the answer recorded, and it is not a census of what Americans believe about death. On the other side, Indian law has its own history in this area: in 2018, in Common Cause v. Union of India, the Supreme Court of India recognised a right to die with dignity and gave legal standing to advance directives, under procedures it later revised. And households in both countries vary enormously in how they weigh the voice of the person who is ill against the voices of the people who love her. A physician who arrives believing that individualism lives on one side of the ocean and family on the other will misread patients on both.
So the form should be learned as a form: its routing, its timing, the place where it is recorded, the state law it points to. The conversation it supports should be learned as a clinical skill, practised and supervised like any other. And the philosophy should be held loosely, as a hypothesis about the particular patient in the bed, to be tested by asking her. Here the four categories are all present at once. The routing is institutional. The legal frame is national, and partly regional, since the statute refers patients to the law of their state. The tone in which the question is asked varies with the person asking. And the judgement about whether a patient understands what she is being asked is clinical. A newcomer who sorts them can learn each part at its own speed. A newcomer who does not may find himself treating the paperwork as the substance and the substance as paperwork.
The Price of Asking #
There is a real emotional difference between asking for information and feeling obliged to prove competence, and from the inside the two are hard to tell apart. A question from someone secure in his standing is simply a request. The same question from someone who suspects he is being assessed becomes an exhibit. Its content is identical. What changes is the cost of asking, and that cost is set largely by what the asker believes the listener is thinking.
Institutions tend to measure the cost of questions badly because they see only the questions that are asked. The ones that are not asked leave no trace, unless they leave an error. Silence is poor evidence of understanding, and the ritual sentence at the end of an orientation session, Any questions?, is a weak instrument for detecting confusion, since it asks the confused person to announce himself before a room. It usually produces silence, and the silence is then recorded, in the institution’s memory, as comprehension.
Organisational research has been unsentimental on this point. In the 1990s the management scholar Amy Edmondson studied hospital nursing units and found, to her initial surprise, that the units with better leadership and working relationships reported more medication errors, not fewer. Her reading, which later work on what she called psychological safety developed, was that people in those units were more willing to report their mistakes, not more prone to make them. Whether a question is asked, or an error disclosed, depends a great deal on whether asking feels safe.
That puts much of the burden on supervisors, and it is a light burden to carry well. What here is unfamiliar to you? invites an answer in a way that Any questions? does not. A sentence such as Everyone asks this in their first month costs nothing and lowers the price of the next question considerably. Distinguishing out loud between the hospital’s rules and one’s own preferences, this is policy, this is just how I like it, gives a newcomer the classification he cannot yet make for himself. None of this requires lowering a standard. It requires making the standard legible.
The newcomer’s side of the bargain is harder, because it asks him to pay a price that the institution may not yet have lowered. When safety is in question, he must ask anyway. A question costs the asker a little standing for a little while. An error costs the patient, sometimes permanently. The exchange is not equal, and the newcomer who understands that will ask the embarrassing question about the abbreviation, the date or the form, and accept the cost as part of the work.
Both Directions #
Orientation is usually imagined as running one way, from the institution that knows to the newcomer who does not. It can run the other way too. A newcomer’s question can reveal that a local practice is unclear to everyone. Asked which date format the hospital uses on its forms, a department may discover that it uses several, inherited from different systems and different decades, and that nobody had noticed because everyone reads them the same way. Asked why a step is done in a particular order, a team may find that the only answer is history. The person who does not yet know the habit is, for a short time, a free audit of it, and an institution that listens can use the audit before familiarity closes it.
That is the generous view, and it needs its strongest objection. Patients do not exist to provide a newcomer with a formative experience. A safety system cannot grade on a curve; a medication given to the wrong patient because a date was misread is the same error whatever the reason for the misreading. Talk of adjustment and hidden curricula can become an alibi for genuine gaps in knowledge, and an institution that is kind about unfamiliarity may slide into being careless about competence. On this view the right response to a newcomer is the same standard on the first day as on the last, applied without commentary.
The objection is right about the standard. The patient’s risk does not change with the doctor’s history, and the obligation to identify the right patient, give the right drug and explain the plan clearly applies from the first shift. But the opposite emphasis has costs that are just as real. If every unfamiliarity is treated as a deficiency, newcomers learn to hide what they do not know, and hidden ignorance is the most dangerous kind. A standard enforced by stigma produces silence, and silence, as Edmondson’s units suggest, is where errors go unrecorded.
The way through is the sorting. The standard is the same for everyone; what differs is the route to meeting it, and the classification of a gap tells you where the checks belong. A clinical gap calls for study, closer supervision and, if necessary, limits on independence until it is closed, and none of that should be softened by euphemism. A gap in convention calls for a system, a reminder, a habit of writing the month in letters, a list of local abbreviations, and should not be mistaken for a gap in medicine. Confusing the two does harm in both directions. Treat a convention gap as a clinical deficiency and you humiliate a capable person and teach him to stop asking. Treat a clinical deficiency as a convention gap and you endanger a patient while congratulating yourself on your tolerance.
The Saving Mark #
Conrad wrote the best short account I know of competence arriving unevenly, and he did it at sea. In “The Secret Sharer,” first published in 1910, a young captain takes command of a ship he does not know, among officers who have sailed together and know one another well. He is a capable seaman, newly given the command, and he is, in his own words, “a stranger to the ship.” Then he adds, with Conrad’s characteristic honesty, that he was “somewhat of a stranger to myself.”
At the story’s climax he takes the ship dangerously close to an island at night, for reasons the story makes urgent, and in the darkness he cannot tell whether she is moving forward or drifting back. A seaman who knew her would feel it. He does not yet. What saves him is a floppy white hat, his own, which he had pressed on someone else’s head moments before and which now floats on the black water. By its position he can see the ship’s motion relative to the sea, and give the right order in time. Conrad’s phrase for what the hat does is exact: it serves “to help out the ignorance of my strangeness.” A few lines later the ship is safe, and in the story’s closing paragraphs the captain feels the silent knowledge that binds a seaman to his first command.
It is tempting, though it cannot be proved, to hear in that passage the experience of a man who learned English and the conventions of British ships together, in his twenties, and who must have needed a good many marks on the water before the silent knowledge came. What the story shows, whatever its sources, is the order in which competence arrives. The explicit mark comes first. The tacit feel comes later, if it comes at all, and it is built on the marks. There is no shame in needing the hat. The danger lies in pretending to a feel one does not yet have.
A hospital can float a good many hats, and some of them are already standard. Writing the month in letters, at least in one’s own notes, removes the 132 dangerous days at a stroke. Asking a patient to state her own name and date of birth, rather than reading them to her and waiting for a nod, is common practice in patient identification for reasons that have nothing to do with newcomers, and it helps them especially. When a woman says the fourth of March, the spoken month settles what the digits on her wristband could not. Her voice carries the convention of the country inside it, and the ambiguity disappears in the act of asking. Glossaries of local abbreviations, a supervisor’s habit of labelling policy as policy and preference as preference, and an orientation that asks newcomers what they found unclear and then changes the next orientation: all of these are marks on the water.
What a doctor trained abroad brings to a new hospital, then, is several kinds of not-knowing at once, and the main skill, for him and for the people who teach him, is telling them apart. The year does not end them. Learning a country and learning a hospital are not finished on the same timetable, and neither is finished in twelve months. What changes is the newcomer’s relationship to his own uncertainty. He learns where the edge of his knowledge runs, and that it runs through odd places, through medicine and also through a calendar, a floor plan, a three-letter abbreviation, and he learns to speak from that edge accurately, saying plainly where his knowledge stops. That is demanding work even for someone who has never crossed a border. Mature competence, as I understand it now, still contains elementary patches. It simply knows where they are, and keeps a hat on the water until the ship can be felt.
Evidence and Editorial Note #
Documented findings. Public biography: MBBS at Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar (1997–2002); PGY-1 at the University of Arkansas for Medical Sciences, Little Rock (2007–2008). Day-month-year order in India and Britain, month-day-year order in the United States, British-style floor numbering in India, and the names paracetamol, acetaminophen and the American abbreviation APAP: general knowledge. The counts of 132 ambiguous dates, twelve same-number dates and 221 self-correcting dates (222 in a leap year) are the author’s arithmetic. The Joint Commission’s 2003 National Patient Safety Goal to use at least two patient identifiers, not the room number, when taking blood samples or giving medications: the 2003 goals as reported by Relias Media. The Patient Self-Determination Act, enacted in 1990 and effective December 1991, requiring Medicare- and Medicaid-participating hospitals to give adult patients written information on their decision-making rights under state law, including advance directives, and to document whether a patient has one: US General Accounting Office report HEHS-95-135; the non-discrimination and education provisions and the Act’s relation to Cruzan v. Director, Missouri Department of Health (1990) are stated from well-established legal history. Common Cause v. Union of India (Supreme Court of India, 2018) on advance directives: well-established legal history. Michael Polanyi, The Tacit Dimension (1966); Philip W. Jackson, Life in Classrooms (1968); Hafferty FW, Franks R, “The hidden curriculum, ethics teaching, and the structure of medical education,” Academic Medicine 69(11):861–871 (1994), characterised as a conceptual argument; Lee Ross’s 1977 naming of the fundamental attribution error; Amy C. Edmondson’s 1996 study of hospital nursing units and error reporting, described in general terms; Arnold van Gennep, Les Rites de passage (1909); Victor Turner, “Betwixt and Between” (1964), reprinted in The Forest of Symbols (1967); Joseph Conrad’s biography (born 1857; British ships from 1878; master’s certificate and naturalisation 1886; Almayer’s Folly, 1895) and “The Secret Sharer” (1910), quoted from the public-domain text. Facts not linked above rest on standard reference knowledge. Vendor representations. None.
Recollection and tradition. The author’s training sites and dates are his published biography. No specific moment, misunderstanding, colleague, supervisor, patient, question or emotion from the author’s intern year is described. The intern with the advance-directive form is explicitly hypothetical. The resident who is curt with relatives and the patient who states her date of birth are general illustrations, not recollections. No claim is made about what any institution where the author trained taught or failed to teach.
Analysis and forecast. The fourfold classification of unfamiliarity, the reading of internship abroad as a double threshold, the stacking of hidden curricula, the treatment of the advance-directive form as procedure rather than national philosophy, the reply to the counterargument, and the readings of Turner and Conrad are the author’s present-day interpretation as of November 6, 2026. Independence. This essay is not sponsored by any institution, company, health system or technology developer. It is personal reflection, not medical or legal 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.