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posts/118386662.year-of-refinement.html +1 -0
posts/154001625.the-year-of-temperance.html +1 -0
posts/154903495.delivers.csv +2 -0
posts/154903495.meet-the-new-boss-same-as-the-old.html +1 -0
posts/155890875.delivers.csv +3 -0
posts/155890875.opens.csv +5 -0
posts/155890875.the-strength-of-simplicity.html +1 -0
posts/161688599.delivers.csv +14 -0
posts/161688599.lessons-at-the-edge-of-the-map.html +1 -0
posts/161688599.opens.csv +15 -0
posts/162005588.delivers.csv +19 -0
posts/162005588.opens.csv +18 -0
posts/162005588.small-talk-at-dawn.html +1 -0
posts/162423754.delivers.csv +25 -0
posts/162423754.grafted-knowledge.html +1 -0
posts/162423754.opens.csv +23 -0
posts/163146048.delivers.csv +25 -0
posts/163146048.opens.csv +17 -0
posts/163146048.playthings-of-the-gods-ai-in-medicine.html +1 -0
posts/163669936.a-preemptive-apology.html +1 -0
posts/163669936.delivers.csv +26 -0
posts/163669936.opens.csv +23 -0
posts/165418131.building-servers-of-babel.html +1 -0
posts/173397840.alternative-data-in-medicine.html +1 -0
posts/174889396.an-application-to-visual-astronaut.html +1 -0
posts/174889396.delivers.csv +36 -0
posts/174889396.opens.csv +34 -0
posts/178099482.delivers.csv +39 -0
posts/178099482.opens.csv +35 -0
posts/178099482.synthetic-data-in-medicine-ethical.html +1 -0
posts/84529288.coming-soon.html +1 -0
src/build_index.py +71 -0

posts/118386662.year-of-refinement.html ADDED Viewed

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+ <div class="captioned-button-wrap" data-attrs="{"url":"https://substack.com/refer/dominictanzillo?utm_source=substack&utm_context=post&utm_content=undefined&utm_campaign=writer_referral_button","text":"Start a Substack"}" data-component-name="CaptionedButtonToDOM"><div class="preamble"><p class="cta-caption">Start writing today. Use the button below to create your Substack and connect your publication with Faith Cadet</p></div><p class="button-wrapper" data-attrs="{"url":"https://substack.com/refer/dominictanzillo?utm_source=substack&utm_context=post&utm_content=undefined&utm_campaign=writer_referral_button","text":"Start a Substack","hasDynamicSubstitutions":false}" data-component-name="ButtonCreateButton"><a class="button primary" href="https://substack.com/refer/dominictanzillo?utm_source=substack&utm_context=post&utm_content=undefined&utm_campaign=writer_referral_button"><span>Start a Substack</span></a></p></div><p>Medical school is flying by quickly and I love to joke that the accelerated curriculum (<a href="https://twitter.com/dominictanzillo/status/1599845475464552449?s=61&t=v6s7w1hNK0-CpX3u4AiCCQ">which I signed up for</a>) makes it very difficult to appreciate just how much and how quickly it is all going. Which is why I am so grateful for the season of Lent.</p><p>During Lent, I necessarily slowed down, cut down on my usage of electronic devices and began contemplating what especially matters. </p><div class="subscription-widget-wrap-editor" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe","language":"en"}" data-component-name="SubscribeWidgetToDOM"><div class="subscription-widget show-subscribe"><div class="preamble"><p class="cta-caption">Thanks for reading Faith Cadet! Subscribe for free to receive new posts and support my work.</p></div><form class="subscription-widget-subscribe"><input type="email" class="email-input" name="email" placeholder="Type your email…" tabindex="-1"><input type="submit" class="button primary" value="Subscribe"><div class="fake-input-wrapper"><div class="fake-input"></div><div class="fake-button"></div></div></form></div></div><p>For both years I have really been a practicing Catholic and celebrated Lent I have begun to reflect on the previous year and look forward for what to expect soon. Last year, I contemplated the Transcendental Principle of Truth and how it relates to Duty really looks like to produce this <a href="https://catholicismcoffee.org/pursuing-duty-in-the-desert-b4ff0e5d2b3c">essay</a>. </p><p>Now in 2023, I have come to appreciate that this last year has been dedicated to Transcendental Principle of Goodness and how it relates to the faith. I now understand that much of the Beauty of Catholicism has to do with Inversion with the least become the first. I’m still writing that essay but for this year I wanted to suggest something else.</p><p>Much like Babe Ruth calling his shot - I’ll tell you what this year is about before I pursue it. There’s a greater risk in doing so because I’ve opened up the possibility of failure - it’s a risk I’m willing to take.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!_SPA!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!_SPA!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg 424w, https://substackcdn.com/image/fetch/$s_!_SPA!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg 848w, https://substackcdn.com/image/fetch/$s_!_SPA!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!_SPA!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg" width="1456" height="1259" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":1259,"width":1456,"resizeWidth":null,"bytes":558990,"alt":null,"title":null,"type":"image/jpeg","href":null,"belowTheFold":false,"topImage":true,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!_SPA!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg 424w, https://substackcdn.com/image/fetch/$s_!_SPA!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg 848w, https://substackcdn.com/image/fetch/$s_!_SPA!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!_SPA!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4da8a3d8-fcac-4a65-8131-5a195c9b39ad_1800x1557.jpeg 1456w" sizes="100vw" fetchpriority="high"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><p>This next year is really the dedicated to the Third Transcendental which is Beauty. Is it a tall order to say, I will live my life beautifully? Perhaps. But what isn’t a tall order is to suggest that this next year will focus on <strong>Refinement</strong>. </p><p>We can take a fundamental principle from medical school - the idea that telomeres are nature’s solution to cancer and apply it to understand what is beautiful. See if cells go rogue and start to replicate endlessly they become a threat to the host - that is cancer. Naturally, living beings have a limit on how many times a cell can replicate by putting a cap on the DNA. Each time the DNA replicates this telomere cap shortens. </p><p>This illustrates the idea that limiting things, saying no, and refining is what makes life possible. This is also true of beauty and expertise. For a person to dabble in a million different skills, he or she will be a novice across all of them. Only by cutting through the noise and really focusing one’s attention on a limited number of things can we become experts.</p><p>Why does this matter especially now. Well my heart is torn in a million directions - I have interests in space, medicine, and religion, and am pursuing projects in each of the fields. I have, depending on how I count it, 4-6 research projects each with different mentors all working at different paces. </p><p>As I reflect I anticipate that during a clinical year wherein I am spending almost all my time in the hospital I will run into an issue trying to maintain what I have found possible during this first year. Namely, I am acting as a “Jack of All Trades, And Master of None.” Much like a tumor who begins malignant growth in any and every direction, this is not sustainable for someone who wants a professional career that signals expertise. It will of course lead to unhappiness.</p><h2>Refining the Definition of Refinement</h2><p>Well then, the solution is to restrict the growth. Perhaps the first treatment is to stop new growth. That is to say, with my current projects, not to add any more on. Not to start another activity and really look to finish the things sitting in my “inbox.” </p><p>This is an issue I’ve talked about before - but the all-to-common “Eyes Bigger than Stomach Syndrome” is a very common issue in medical school. Especially, as I’ve confided in my classmates, it seems for first-generation medical students. </p><p>Unlike some of our peers who are the children of double-doctor households and/or will be third or even fourth generation physicians and therefore have a sense of confidence, we have commiserated that it is difficult to say no to more opportunities.</p><p>So refinement looks like saying no to all the extra noise - focusing on a narrow array of opportunities. Refinement also looks like cultivating expertise in medical school and then a narrow subset of things of things outside of medical school. So now, I’ll include things that I will look to maintain outside of school, things that bring me joy, but so that I can become more of an expert in them:</p><ul><li><p>Writing, especially on how faith practically intersects with life and classroom learning</p></li><li><p>Cooking</p></li><li><p>Weightlifting</p></li><li><p>Training for Triathlon</p></li></ul><p>That means actively looking to improve and when I have free time, considering these before considering other activities. These hobbies are more than enough but if there is one, and only one, new thing I would like to add to this list it might be <strong>Swing Dancing</strong>. But in the spirit of refinement, I’ll focus on that list for now and see if it keeps me busy. </p><p>I’ll do the other things I enjoy like hiking or Scuba Dive but I’ll tag along with others for those activities rather than actively pursue them by myself. It also means saying no for the things I really want to do and actively carving out and dedicating time to them.</p><p>I’ve tinkered with lots of applications and right now <a href="https://www.sunsama.com">Sunsama</a> feels really good for integrating with my calendar and class schedule - for knowing what I should be working on and when.</p><p>So here’s to celebrating a new year, this time with a refining perspective.</p><div class="subscription-widget-wrap-editor" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe","language":"en"}" data-component-name="SubscribeWidgetToDOM"><div class="subscription-widget show-subscribe"><div class="preamble"><p class="cta-caption">Thanks for reading Faith Cadet! Subscribe for free to receive new posts and support my work.</p></div><form class="subscription-widget-subscribe"><input type="email" class="email-input" name="email" placeholder="Type your email…" tabindex="-1"><input type="submit" class="button primary" value="Subscribe"><div class="fake-input-wrapper"><div class="fake-input"></div><div class="fake-button"></div></div></form></div></div>

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+ <p>As the new year unfolds, I have chosen to name it the Year of Temperance, a resolution inspired by the classical virtue that has resonated through centuries of moral philosophy. Temperance, often depicted as a balanced and measured life, encompasses a steadfast commitment to moderation and self-control. As president of the Duke Catholic Center, this virtue serves as a compass, guiding me to maintain focus on the commitments I have already made and to honor them with unwavering diligence. It is also the virtue I randomly drew out of a hat, associated with St. Thomas Aquinas.</p><p>Temperance, as a virtue, is often misunderstood as mere abstinence. While it indeed includes practices like abstinence (moderation in food), sobriety (moderation in drink), and chastity (moderation in sexual desires), its essence is far richer. It is about ordering one’s life towards the good—not simply avoiding excess but fostering balance to pursue higher goals. This year, my particular application of temperance extends into the modern realm of “<a href="https://link.springer.com/article/10.1007/s10676-022-09674-7">Digital Temperance,</a>” an adaptation of this ancient virtue for our technological age. In a world dominated by screens and endless digital distractions, this form of temperance demands intentionality and discipline in the use of technology.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080 424w, https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080 848w, https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080 1272w, https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080 1456w" sizes="100vw"><img src="https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080" width="530" height="736.0668670172803" data-attrs="{"src":"https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":3697,"width":2662,"resizeWidth":530,"bytes":null,"alt":"astronaut standing on gray sand","title":null,"type":"image/jpg","href":null,"belowTheFold":false,"topImage":true,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="astronaut standing on gray sand" title="astronaut standing on gray sand" srcset="https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080 424w, https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080 848w, https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080 1272w, https://images.unsplash.com/photo-1541873676-a18131494184?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwxfHxhc3Ryb25hdXR8ZW58MHx8fHwxNzM1ODUyNTk2fDA&ixlib=rb-4.0.3&q=80&w=1080 1456w" sizes="100vw" fetchpriority="high"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Like the astronaut, I need to be locked in. Photo by <a href="true">History in HD</a> on <a href="https://unsplash.com">Unsplash</a></figcaption></figure></div><p>The inspiration for this focus stems from the realization that my obligations in the coming year will tether me to screens. Publishing academic work, studying for pivotal exams, and finalizing applications for residency programs require sustained time in front of computers. These pursuits, while essential, carry the risk of drawing me into the vortex of digital noise—a realm where focus is fractured and time is stolen. Thus, Digital Temperance becomes not just a practical strategy but a moral commitment: to ensure that my use of technology serves my higher purposes rather than undermining them.</p><p>To this end, I am implementing measures to mitigate unnecessary screen time. This includes leveraging tools like the <a href="https://freedom.to/">Freedom App</a> to impose strict boundaries on my phone usage, blocking non-essential apps to create space for deep work and reflection. These practices reflect a deeper commitment to align my actions with my intentions, fostering a life of purpose and integrity.</p><p>The Year of Temperance is not merely a personal ambition but a reminder of the importance of steadfastness and balance in a world of constant distraction. By anchoring my days in this virtue, I hope to cultivate a life that is not only productive but deeply rooted in the values that matter most.</p>

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1	+ post_id,timestamp,email,post_type,post_audience,active_subscription
2	+ 154903495,2025-01-15T19:09:40.720Z,matias@sincerelymatias.com,newsletter,everyone,true

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+ <p>In a recent medical ethics course, there was a debate over the question of professionalism. Is it just the baseline of acceptable conduct—the thing that keeps teams functional, patients respected, and everyone more or less on the same page? Or is it something grander, a set of higher virtues unique to medicine and its practitioners?</p><p>This isn’t just a debate about definitions; it’s a deeper inquiry into the soul of modern medicine. What is this profession—a calling, or just another job?</p><h3>Minimal Standards</h3><p>If professionalism is a set of minimal standards, then it has to function like a rulebook: clear, enforceable, and pragmatic. As medical students, we know this version of professionalism intimately. Showing up late, wearing the wrong thing, or slipping in decorum? Unprofessional. Sanctions and warnings follow. This professionalism keeps the trains running on time; it’s the lubricant for the machine that is modern healthcare.</p><p>Think of it as compliance. Doctors and students alike align themselves with the expectations set by their superiors. In this world, you adopt a mindset best summed up by The Who: “Meet the new boss, same as the old boss.” Your attending physician’s quirks, style, and preferences largely define the line between acceptable and unprofessional. This is rooted in humility and the expectation that your superior who has gone before you knows how to operate in this high-stakes environment. Personal ambitions and conceptions of the good? Admirable, but ultimately incidental. These larger goals may be fostered by good mentors but could they ever be encompassed by the term professionalism?</p><p>There’s no denying the stakes in medicine—life and death hover over decisions—but this understanding of professionalism mirrors the systems found in any hierarchical organization. Whether you’re bolting parts on an assembly line or scrubbing in for surgery, the principle is the same: follow the standards, keep the team on track, and avoid unnecessary disruptions. When leadership fails to uphold these ethical standards, pushback is inevitable because professionalism is a two-way street. Professionalism in this framework is a minimal ethic, more about preventing chaos than fostering virtue.</p><p>Medicine, however, does have unique expectations that go beyond the assembly line. Respect for patients is paramount—it’s what builds trust, allowing people to share their most intimate vulnerabilities and agreeing to allow a surgeon to operate on them. This trust extends beyond the hospital, demanding that healthcare professionals uphold standards in their personal lives to avoid compromising it. Yes, these are elevated standards, but they remain fundamentally pragmatic. A doctor’s obligation to perform CPR on a collapsing stranger isn’t an emergent principle of medicine; it’s a recognition of shared humanity and interdependence. Medicine’s ethical principles emerge from this universal truth, not from some esoteric code.</p><p>Practical? Absolutely. Scalable? Without question. But does this focus on the mechanics flatten what medicine could be?</p><h3>Noble Aspirations</h3><p>Here’s the counterargument: professionalism is not about floors but ceilings. It’s not just the baseline; it’s a reach for something higher—a demonstration of care, compassion, and integrity that elevates medicine into a calling.</p><p>Let’s talk about the privileges afforded to medicine. Along with law, mental health, and clergy, it’s one of the few professions granted special Fifth Amendment protections. Why? Because it touches on the intangible yet essential elements of human existence: life, liberty, and the soul. The physician who prioritizes a patient’s health over profits or challenges unjust laws to provide care exemplifies this elevated professionalism.</p><p>And consider the gauntlet that is medical education. From nursing programs to physical therapy schools to medical residencies, the barriers to entry are brutal. It’s a system designed to filter out all but the most committed. Those who opt in and endure the crucible are exceptional by definition. Their willingness to sacrifice comfort, time, and energy is itself a testament to a higher standard of dedication.</p><p>Medicine’s moral framework isn’t unique. It reflects universal principles—an ethic of life, liberty, and the pursuit of happiness—applied to the body and health. The doctor preserves life, the lawyer safeguards liberty, and the clergy nurtures the soul. Together, they operate within a shared moral ecosystem. But this view—aspirational, virtuous, and grand—risks complicating the idea of professionalism.</p><h3>Beyond Professionalism: The Accidental Virtue</h3><p>Here’s where it gets tricky. If we tie these lofty ideals directly to professionalism, we risk overloading the term. Professionalism, at its core, is a set of standards—a floor, not a ceiling. It ensures that the system functions smoothly. It cannot and should not be the vehicle for individual greatness.</p><p>What’s needed is a term for those loftier ambitions. Call it "vocational mastery"—a pursuit of excellence that grows organically from a practitioner’s character and dedication. Mastery can’t be enforced. Virtue, after all, loses its meaning the moment it’s mandated. It thrives in the space beyond obligation, where it is chosen freely.</p><p>That said, personal mastery has its dangers. Too much self-regard can push medicine into the realm of the Tower of Babel—a monument to hubris rather than healing. When practitioners chase recognition over good, the field risks losing sight of its proximate goal: improving health. Professionalism, with its emphasis on high but clear standards, acts as a counterweight. It keeps the focus on the patient, not the practitioner’s ego.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!YIOa!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!YIOa!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp 424w, https://substackcdn.com/image/fetch/$s_!YIOa!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp 848w, https://substackcdn.com/image/fetch/$s_!YIOa!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp 1272w, https://substackcdn.com/image/fetch/$s_!YIOa!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp" width="450" height="297.75" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":397,"width":600,"resizeWidth":450,"bytes":29464,"alt":null,"title":null,"type":"image/webp","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!YIOa!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp 424w, https://substackcdn.com/image/fetch/$s_!YIOa!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp 848w, https://substackcdn.com/image/fetch/$s_!YIOa!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp 1272w, https://substackcdn.com/image/fetch/$s_!YIOa!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7abde802-aed8-4539-a5a0-840787c743c4_600x397.webp 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><p>Professionalism, then, is the anchor. It’s the realm of "Meet the new boss, same as the old boss" and #DoTheWork, ensuring that healthcare operates efficiently and ethically. Vocational mastery is the accidental virtue—the thing that elevates a good doctor to greatness but cannot and should not be required lest it loses all meaning.</p><p>This separation preserves the integrity of professionalism while leaving room for individual aspiration. Every doctor must be professional, but not every doctor will pursue vocational mastery—although they should. And that’s okay. Virtue is meaningful only when it’s chosen, not compelled. Medicine, in the end, remains both a profession and, for some, a calling. It’s grounded in standards but open to the extraordinary heights of those who choose to go further.</p>

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+ <p>After high school and before college, I asked my father to drive with me through the American Southwest. I had grown restless in the symmetry of suburbia, in the streets that curved back upon themselves like questions never answered. The houses all the same, their lawns clipped and watered, their lights burning against the dark as if to keep the world at bay. The air there had no weight. Even the quiet felt manufactured. I wanted to see a land that could not be tamed, to stand beneath a sky so wide it could strip a man down to what was true.</p><p>My father agreed to the trip, though it was not his kind of thing. He liked the routine of the auto shop, the precision of diagnosing problems and fixing them. Vacations, to him, were unnecessary. But he said yes, maybe because he understood this was about more than just the trip.</p><p>We visited the great landmarks: the Grand Canyon, Arches, Bryce Canyon. They were magnificent, but what stayed with me were the miles between them. The desert of Arizona and the planes of Montana unfolded endlessly, their emptiness interrupted only by a gas station or a humble roadside town. That vastness pressed down on me, not with weight but with presence. You cannot look at that much space without feeling it reconfigure something inside you.</p><p>My father did not talk much on that trip, especially when he was behind the wheel. His words came in small, deliberate portions, as if each required careful thought before it left his mouth. Once, I asked what he thought of the landscape. He looked out across the horizon and said, “It’s quiet. Lets you think.” That was all. Yet in that quiet, I began to hear him differently. His silences were not absences but choices. They were full of meaning, like the space between stars.</p><p>That journey became a point of reference for my life. It marked the end of my childhood and the beginning of something more deliberate. I learned that simplicity is not emptiness. It is clarity. The barren landscape stripped away noise and distraction until all that remained was the truth of who I was: flawed, uncertain, but alive.</p><p>One evening near the Grand Canyon, I stepped outside after sunset. The sky had turned violet, then black, pierced by a scatter of stars so sharp they looked close enough to touch. This was not the polite glow of the suburbs but the raw expanse of the Milky Way, visible in its entirety. I felt small, yet profoundly connected. The stars did not care about me, but they acknowledged my existence by their very presence. In that moment, insignificance felt sacred.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!gZrq!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!gZrq!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp 424w, https://substackcdn.com/image/fetch/$s_!gZrq!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp 848w, https://substackcdn.com/image/fetch/$s_!gZrq!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp 1272w, https://substackcdn.com/image/fetch/$s_!gZrq!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp" width="960" height="512" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":512,"width":960,"resizeWidth":null,"bytes":40720,"alt":null,"title":null,"type":"image/webp","href":null,"belowTheFold":false,"topImage":true,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!gZrq!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp 424w, https://substackcdn.com/image/fetch/$s_!gZrq!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp 848w, https://substackcdn.com/image/fetch/$s_!gZrq!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp 1272w, https://substackcdn.com/image/fetch/$s_!gZrq!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4df6f383-fc2c-48a0-909d-f635d8ae3314_960x512.webp 1456w" sizes="100vw" fetchpriority="high"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Night sky over Death Valley - where my family would spend Spring Break</figcaption></figure></div><p>The American West, across its many stories and mythologies, is built on this kind of clarity. The Western is not a genre of complexity but of necessity. Its heroes act because inaction means death. They do not choose simplicity for comfort but because the conditions of survival demand it. Food, shelter, safety are the stakes. There is no room for pretense or delay.</p><p>That understanding has followed me into adulthood. It explains my fascination with both space and medicine. As a child, I watched <em>Star Wars</em> with my father, never realizing how deeply it would connect us. Now, revisiting those films is difficult, a reminder of what is gone. My interest in space was never about fantasy. It was about edges and frontiers, the places where life is reduced to essentials.</p><p>At NASA, physicians face questions that make earthly debates feel distant. Should a three-year mission include antibiotics, or should every ounce of space go to food? There is no luxury of indecision. Medicine in space is stripped to its core, where the only metric is what works. The frontier once defined by the Western now extends beyond the atmosphere, yet the principle remains unchanged: simplicity as necessity.</p><p>I thought about this during a medical ethics seminar today. We debated language—what it means to coach rather than nudge, how authority intersects with autonomy. Such discussions have value, but sometimes they fracture meaning until only fragments remain. The pursuit of precision can dissolve understanding.</p><p>Then someone raised the question of suicide. Could a person rationally and deliberately choose to end their life without depression? The room grew tense, filled with abstract reasoning. For me, it was no longer abstract. My father’s death lingers in my mind, not as a memory but as a question I will never fully answer. Time has softened its edges, but the ache remains. Today, though, I could sit with it. I could let it exist without consuming me.</p><p>Later, biking home in the cold, I looked up at a dim sky veiled by city light. Only a few stars broke through, faint but steady. Even those sparse lights carried me back to that same sense of clarity. It is not something I rediscover; it is something that finds me. Beneath the layers of work and worry, it waits. It is quiet, constant, unshakable.</p><p>Clarity has a rhythm. It arrives when distraction falls away, revealing what has always mattered: purpose, integrity, and the courage to face truth without embellishment.</p><p>Maybe one day, I’ll see Earth from space. As a kid, I never dreamed of being an astronaut, but the vision of our planet as a fragile, luminous marble suspended in the void offers a clarity few will ever know. Astronauts call it the <em>Overview Effect</em>, the sudden awareness of how small our conflicts are and how inseparable our lives remain.</p><p>For me, a dream of space isn’t about escape. It’s about isolation and love—reconciling the emptiness of the universe with the beauty that persists within it. It’s about standing at the edge of everything and realizing that even the smallest choices matter. It’s about honoring my father—his strength, his honesty, and his ability to face the world as it was, without pretense.</p><p>When I read a Western, those truths return. Simplicity is not easy. It demands honesty, discipline, and the willingness to confront oneself. My father embodied that. The desert revealed it. Medicine continues to teach it. The night sky affirms it.</p><p>And perhaps, if I ever stand at the edge of the world and look back, I will see it all as it truly is: small, essential, and profoundly meaningful.</p>

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+ <p>Duke Medicine hums like a crowded launchpad. On the first morning I signed in, shaking hands felt less like meeting classmates and more like leafing through a living anthology of American over‑achievement: Special forces operators who had swapped helmets for stethoscopes; professional athletes who managed to navgiate perfect GPAs; CDC epidemiologists fluent in fieldwork; lab veterans from NASA already thinking about bones in microgravity. The nametags alone—Harvard, Stanford, Dartmouth, UCLA, and, of course, Duke—could have doubled as a dean’s‑list of the republic. Yet for all that wattage, one truth announced itself early: intellectual horsepower is no guarantor of interior formation. The white coat may advertise competence, but it cannot confer character.</p><p>That discovery did not arrive in a grand‑rounds epiphany. It seeped in from the edges—corridors unpatrolled by syllabi, waiting rooms no OSCE can reproduce. Lectures stockpile facts; clerkships refine technique; but the kind of wisdom that steadies a physician—indeed, any adult—begins where the curriculum ends. It asks us to tread unlit ground, to negotiate ambiguity, to sit with stories that cannot be solved by the next order set. The irony is plain: the structure that shields us from chaos also delays the tensile strength that chaos alone can forge.</p><div class="subscription-widget-wrap-editor" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe","language":"en"}" data-component-name="SubscribeWidgetToDOM"><div class="subscription-widget show-subscribe"><div class="preamble"><p class="cta-caption">Thanks for reading Space Cadet! Feel Free to Subscribe to hear more.</p></div><form class="subscription-widget-subscribe"><input type="email" class="email-input" name="email" placeholder="Type your email…" tabindex="-1"><input type="submit" class="button primary" value="Subscribe"><div class="fake-input-wrapper"><div class="fake-input"></div><div class="fake-button"></div></div></form></div></div><p>Over the past research year—our designated intermission between core rotations—those edges became my classroom. In that space between protocol and improvisation, three tutors emerged: the marginalized, the student, and solitude itself. Each offered a lesson on how to grow a soul sturdy enough for the wards.</p><h3>Compassion: Let the Outskirts Speak</h3><p>Medicine attracts people eager to fix, yet its deepest schooling comes when we cannot fix much at all. Gabriel taught me that. He is a young man with cerebral palsy who rolled into our parish community asking for confirmation instruction earlier this year. Sponsoring him was supposed to be an exercise in catechesis; it became a practicum in dependency. Gabriel’s calendar is a logistical opera: rides booked days in advance, meals negotiated bite by bite, sentences penned by voice-to-text. What looks like limitation from the outside is for him a native fluency in trust. Where I hoard self‑sufficiency, he spends it lavishly.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!CCes!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!CCes!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg 424w, https://substackcdn.com/image/fetch/$s_!CCes!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg 848w, https://substackcdn.com/image/fetch/$s_!CCes!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!CCes!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/e6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg" width="360" height="378.494623655914" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/e6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":2640,"width":2511,"resizeWidth":360,"bytes":1821438,"alt":null,"title":null,"type":"image/jpeg","href":null,"belowTheFold":false,"topImage":true,"internalRedirect":"https://dominictanzillo.substack.com/i/161688599?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa787881b-8923-4481-ab40-f944841f9941_4032x3024.jpeg","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!CCes!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg 424w, https://substackcdn.com/image/fetch/$s_!CCes!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg 848w, https://substackcdn.com/image/fetch/$s_!CCes!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!CCes!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6dfdf39-9bec-43d9-8621-de3f73d416c2_2511x2640.jpeg 1456w" sizes="100vw" fetchpriority="high"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Gabriel and I back in December, when confirmation classes began.</figcaption></figure></div><p>Our friendship forced me to admit how allergic I am to asking for help. I wait until the roof leaks; he calls before the storm. On nights we compared notes about losing our fathers as teenagers—his calm, my anger—I watched the <a href="https://www.goodreads.com/quotes/10642883-among-the-most-beautiful-things-i-ve-ever-heard-anyone-say">sharp edges of my grief sand down</a> under the weight of his matter‑of‑fact acceptance. Today I have the privilege of watching him walk towards the altar today for confirmation, I felt less like a mentor and more like the beneficiary of an unscheduled retreat in humility.</p><p>The lesson repeats weekly at the food pantry—the place we first met and now work alongside each other. I arrive to dispense groceries and help manage the warehouse but leave stocked with something heavier: the realization that gifts flow both directions and the giver often walks away richer. Compassion, then, is not pity extended downward but kinship discovered sideways. The patient is not a project; he is a mirror.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!WFgx!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!WFgx!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg 424w, https://substackcdn.com/image/fetch/$s_!WFgx!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg 848w, https://substackcdn.com/image/fetch/$s_!WFgx!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!WFgx!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/b5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg" width="466" height="349.5" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/b5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":1092,"width":1456,"resizeWidth":466,"bytes":5881392,"alt":null,"title":null,"type":"image/jpeg","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/161688599?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!WFgx!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg 424w, https://substackcdn.com/image/fetch/$s_!WFgx!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg 848w, https://substackcdn.com/image/fetch/$s_!WFgx!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!WFgx!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb5b2fa1d-6fe9-4d2d-bed9-eab565b14ad1_5712x4284.jpeg 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Everyone at the Durham Community Food Pantry.</figcaption></figure></div><p>One April afternoon walking on the campus, guiding Gabriel’s wheelchair across the slick flagstones became a slow choreography of trust: he steering the conversation, I steering our balance. Each cautious pivot felt like a wordless homily: love is the sum of micro‑adjustments that keep another human upright.</p><p>True formation starts when the self tilts outward. Only then do the instruments of healing find their pitch.</p><h3>Teaching: Responsibility as Mirror</h3><p>Building <strong><a href="https://bassconnections.duke.edu/project/virtual-reality-health-education-advanced-learning-vr-heal-2024-2025/">VR‑HEAL</a></strong>—our mixed‑reality catheter‑training simulator—was my plunge into pedagogical white‑water. The registrar listed me as one the instructor, but the course operated more like a one-year start‑up incubator welded onto a hack‑a‑thon. One day the head‑mounted displays refused to handshake with the tactile glove’s firmware; on one afternoon a Unity merge ate half our haptic scripts. Every snag forced me to swap podium for tool belt, theory for troubleshooting.</p><p>The most revealing moment arrived at 11 p.m. less than twenty four hours before a live demonstration and final competition. Inside the simulation the virtual catheter kept snapping off‑axis, ricocheting through an acrylic vena cava like a rubber bullet. I was at my wit’s end. Instead, a sophomore comp‑sci major reconfigured the hidden logic of colliders over the span of 30 minutes. Authority dissolved into coalition; the classroom hierarchy flattened in the blue haze of twin monitors.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!Zb12!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!Zb12!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg 424w, https://substackcdn.com/image/fetch/$s_!Zb12!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg 848w, https://substackcdn.com/image/fetch/$s_!Zb12!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!Zb12!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/ba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg" width="3920" height="2940" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/ba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":2940,"width":3920,"resizeWidth":null,"bytes":2561086,"alt":null,"title":null,"type":"image/jpeg","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/161688599?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe82dab4b-6db6-4f9d-867d-06d566ec4bca_4032x3024.jpeg","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!Zb12!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg 424w, https://substackcdn.com/image/fetch/$s_!Zb12!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg 848w, https://substackcdn.com/image/fetch/$s_!Zb12!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!Zb12!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fba34f51e-b464-43f1-af16-72b1ea42dfc9_3920x2940.jpeg 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Demonstrating our Virtual Reality Medical Simulation.</figcaption></figure></div><p>By sunrise the catheter glided through digital vasculature as smoothly as on the bench top phantom. And when the demo landed, when VR‑HEAL captured first place at <a href="https://bassconnections.duke.edu/event/2025-fortin-foundation-bass-connections-showcase/">Duke’s interdisciplinary showcase</a>, the ribbon felt incidental. What lingered was the revelation that teaching is stewardship of other people’s ingenuity. You curate conditions, then you get out of the way.</p><p>In that light, “Instructor” becomes a mirror: whatever poise, curiosity, and patience you project bounces straight back in student form. Knowledge travels a Möbius strip—mentor to pupil, pupil to mentor—until you can no longer tell who drafted the lesson plan.</p><h3>Solitude: Earning Your Own Company</h3><p>The third‑year research block scattered my cohort across the ivory tower. I landed in pathology, <a href="https://medschool.duke.edu/stories/medical-mystery-microgravity-can-space-travel-raise-risk-blood-clots">pipetting astronaut blood samples</a> while studying for Step 2. Days dissolved into centrifuge cycles, evenings into email threads, weekends into code sprints for VR‑HEAL. From the outside: isolation. From the inside: a stripped‑down monastery.</p><p>Three mornings a week I lace up at four‑thirty, long before the hospital’s windows bloom with fluorescent dawn. The Tobacco Trail is empty save for the occasional deer and the soft metronome of shoe against gravel. In that hush the mind rehearses emergencies: cadence steady, scan for obstacles, make the next right decision. By the second mile the pulse has memorized calm; by the fifth it can export that calm to a code‑blue bay.</p><p>Occasionally, I finish my runs in the shadow of the helipad of Duke North, where this academic journey first began. Standing there, I trace the skyline and let the silence fill with vows: to greet chaos with interior order, to let every patient borrow some of the stillness earned before sunrise.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!DpyR!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!DpyR!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg 424w, https://substackcdn.com/image/fetch/$s_!DpyR!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg 848w, https://substackcdn.com/image/fetch/$s_!DpyR!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!DpyR!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg" width="4032" height="3024" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":3024,"width":4032,"resizeWidth":null,"bytes":1166909,"alt":null,"title":null,"type":"image/jpeg","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/161688599?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F480bc0b7-7466-43f0-9883-59950e7aed0d_4032x3024.jpeg","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!DpyR!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg 424w, https://substackcdn.com/image/fetch/$s_!DpyR!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg 848w, https://substackcdn.com/image/fetch/$s_!DpyR!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!DpyR!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F24754ef5-09ff-4802-b383-beab07a88d6b_4032x3024.jpeg 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Helicopters first introduced me to aerospace medicine and always lift my mind to the reason I’m here today.</figcaption></figure></div><p>Left alone, the mind mutinies, then quiets, then starts telling the truth. By the midpoint of the run the internal jury convenes; by the end it renders verdicts impossible to hear in a crowded library. I learned that self‑possession is not the opposite of community but its precondition. A physician who cannot sit with his own silence will demand noise from patients and colleagues alike. Solitude seasons presence; it teaches us to carry calm into crowded rooms.</p><p>Importantly, seclusion is not self‑exile. It is rehearsal space. The notes perfected in private, steadiness, honesty, imaginative attention, become the score we play for others.</p><h3>Discovery: Working the Frontier</h3><p>My fascination with space medicine crystallizes the thesis: growth lives at the threshold. Whether troubleshooting bone‑density loss in orbit or calibrating a catheter in mixed reality, I have noticed the same pattern. Venture too far beyond the protocol, and panic loiters nearby; venture not far enough, and the work calcifies. The edge, where map turns to <em>maybe</em>, is the only field fertile enough for invention.</p><p>Edges are contradictory territories: vacant yet electric, risky yet generative. They demand the physician’s finest virtues—courage tempered by prudence, imagination tethered to evidence. Answers arrive late, dressed as better questions. The reward for surviving uncertainty is a larger interior horizon.</p><p>So, what does any of this say to the first‑year me still dazzled by résumés? (And moreover, a note to my kid brother who will hopefully join me at Duke Medicine in August, congrats to him). Perhaps this: the secret curriculum of medicine runs on a different credit system. Degrees certify skill; the margins certify the person wielding it. Shake as many decorated hands as you like; the measure of a clinician will be taken in quiet rooms where no one is grading.</p><p>Wisdom sprouts in the unlikeliest soil: in dependency that exposes our vanity, in teaching that renegotiates authority, in solitude that disarms the ego, in wild problems that refuse to stay within the lines. Attend to those places and the white coat will fit the soul it covers. Neglect them and even the finest CV will read like an unfinished case report.</p><p>In the end, growth is less a ladder than an orbit—each pass around the margins drawing us closer to the center of what matters: a practiced generosity of mind and spirit, ready to meet suffering with eyes that have learned to see.</p><div class="subscription-widget-wrap-editor" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe","language":"en"}" data-component-name="SubscribeWidgetToDOM"><div class="subscription-widget show-subscribe"><div class="preamble"><p class="cta-caption">Thanks for reading Space Cadet!</p></div><form class="subscription-widget-subscribe"><input type="email" class="email-input" name="email" placeholder="Type your email…" tabindex="-1"><input type="submit" class="button primary" value="Subscribe"><div class="fake-input-wrapper"><div class="fake-input"></div><div class="fake-button"></div></div></form></div></div>

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+ <p>Oliver Bateman <a href="https://substack.com/home/post/p-160815193">is right in his recent viral essay</a>: society runs on phrases worn smooth “like river stones,” their content less important than the cushion they offer between strangers. Yet this is not a lamentable fact, this buffer allows for a social grace without requiring the full weightiness of self-expression and sharing too much.</p><p>To this end, small talk is an art—an elegant means of slipping into and out of conversation. It’s the opening choreography of any human interaction, those first few steps where we may silently ask: do I want to keep dancing with this person?But in the hospital, there’s no such question. This is a job. You must dance with every patient. The subject matter is often grave, the tempo uneven, and the partners not fully prepared. Here, small talk isn’t a prelude. Rather, it’s a synchronizing beat. A way to get two people moving in time before the full weight of the waltz begins.</p><div class="subscription-widget-wrap-editor" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe","language":"en"}" data-component-name="SubscribeWidgetToDOM"><div class="subscription-widget show-subscribe"><div class="preamble"><p class="cta-caption">Thanks for reading Space Cadet! Not much discussion about outer space in this piece but more reflections on conversational space.</p></div><form class="subscription-widget-subscribe"><input type="email" class="email-input" name="email" placeholder="Type your email…" tabindex="-1"><input type="submit" class="button primary" value="Subscribe"><div class="fake-input-wrapper"><div class="fake-input"></div><div class="fake-button"></div></div></form></div></div><p>Before sunrise on the ward, physicians move through familiar steps. Yet something strange and beautiful happens. The linguistic handshake, so often a hollow formality, becomes, within these walls, a slender but sturdy bridge across very real suffering. A smile, a weather comment, a joke about the coffee—these are never empty gestures. They are tools, gentle ones, that make the harder work possible. They exist to be, as Bateman puts it, “reaching out across the void of presumed incommensurability that separates all of us,”</p><p>I’ll admit it up front: I actually enjoy small talk. I’m an extrovert, and novelty excites me. What could be more novel than meeting someone new? </p><p>But I will also confess I wasn’t always good at it. If anything, clinical rotations have been an honors course on the subject. Watching masters of bedside manner move from room to room, each patient a little lighter for having seen the doctor, has taught me how to be a better dancer, so to speak.</p><p>These are a few of the lessons I’ve picked up—observations for anyone hoping to improve their general small talk or their bedside manner for the medically proficient. In the hospital and beyond, the dance is worth learning.</p><h3>Cross the Threshold</h3><p>The first step in dancing with someone is, of course, asking them to dance. Trivial as it sounds, this requires some degree of bravery to initiate the conversation, especially because there is the possibility of rejection. I found Bateman’s line incredibly astute, “The masters of social interaction understand that most human communication isn't about exchanging information. It's about establishing comfort.”</p><p>The first question “How are you, this morning?” is pure formality. In a hospital room, when our objective is to get some medical facts from the patient, then pass our plan to the patient, all in a timely manner (before doing it again with the next patient), there is an impulse to dive into the objectives. But the form of the opening moves still matters. </p><p>The patient may be waking up or was just watching something on the dim hospital television and so asking them that first question, among other things, completely recalibrates their expectations in that moment.</p><p>Just stand at the foot of the bed and you are a clipboard with a pulse. But, step forward, let the patient see your eyes, offer a smile, and the choreography shifts. Point to an untouched tray: “The pancakes lost the morning battle?” Small, safe, almost trivial—yet it shifts the patient from passive object to conversational partner who can tell you why they skipped breakfast and, by extension, why today may not go well.</p><p>Politeness often ends in reflexive deflection: “It is what it is.” When a patient asks me how I am, I answer truthfully but lightly. “Running on one cup of coffee, but the sunrise was worth it.” Vulnerability, even an ounce, levels the floor. In medicine, revealing a single thread of your own life invites a patient to tug on it and reveal the fabric of theirs.</p><p>And its these two essential skills, offering a curious observation and disclosure that allows you to full cross the threshold before jumping into the medical conversation.</p><h3>Ask, Then Listen</h3><p>The troubling truth about small talk is that, more often than not, it vanishes without a trace. It begins, it ends, and carries no memory into the future. That isn’t necessarily a flaw. In fact, there’s value in not holding onto too much.</p><p>Asking someone on an elevator if they’re glad it’s Friday doesn’t really matter. And if I made a point of remembering that every stranger tells me they’re looking forward to the weekend (even if I’m working tomorrow, and it doesn’t feel like a weekend to me) then maybe I’d need to ask for their name, commit their face to memory, and carry that weight around.</p><p>But that’s not the point. Small talk isn’t about building archives. It’s about continuity. Having a next question ready keeps the moment afloat just long enough for both of us to step off the elevator and say, without awkwardness, “Have a nice day.”</p><p>There’s a reason not to force these moments into permanence. Small talk is a kind of social blessing, lightweight, sincere, and fleeting. It’s a quiet way of saying: <em>I see you, and even in this passing moment, I hope the best for you.</em></p><p>But when it’s all rehearsal, when every exchange becomes a mask, and people plan their next line instead of hearing the one being spoken, small talk turns deadly, especially at the bedside.</p><p><a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC9512556/#:~:text=Physicians'%20interruptions%20during%20medical%20visits,average%20of%20just%2018%20seconds.&text=These%20instances%20of%20overlapping%20talk,patients'%20symptom%20presentation%20and%20participation.">Studies show doctors interrupt patients after just eighteen seconds</a>. They’ve got a plan, a list, a clock ticking. But I’d challenge you: give a full minute of silence. One minute, without interruption. That’s when the patient will mention the night sweats, the misplaced dentures, the real reason they rang the call bell at 3 a.m. The small-talk opener, “How did you sleep?” isn’t filler. It protects you both from diving in too soon. But when timed right, it dissolves, and the real story surfaces.</p><p>Because the relationship between a patient and provider is not the same as two strangers locked in an elevator—it’s deeper, more asymmetric, more sacred. And paradoxically, that means there should be <em>more</em> small talk, not less. It buys space, it defuses fear, it gives shape to an experience that otherwise feels like internment. </p><p>For the patient lying in bed post-surgery, one remembered detail, a granddaughter’s birthday or a favorite basketball team (Duke or UNC, take your side), can turn the next morning’s visit into proof of personhood and acknowledgment of our shared human dignity.</p><p>Then, when you ask, <em>“Tell me what you think?”</em> the words ring sincere because yesterday you proved you were paying attention.</p><p>And while it’s easiest if you care for people naturally, not everyone arrives at medicine with that disposition. That’s okay. The chart exists not just for clinical numbers but for reminders: digital sticky notes about what matters. Small talk is the first line of the story. If we write it down, we can pick it up again tomorrow and pick up the person along with it.</p><h3>Can This Be a Game?</h3><p>Dancing is more enjoyable when the goal isn’t to impress the whole room, but simply to enjoy the evening. Much the same can be said for conversation. If small talk feels like a chore, maybe it’s time to treat it like a game.</p><p>Introverts often freeze at the thought of endless chit-chat. One quiet way to make it more bearable (and maybe even fun) is to set secret goals known only to you. In high school English class, our mandatory Socratic seminars often felt tedious, especially when few had done the reading. To pass the time and sharpen our wit, a few friends and I created a competition. We’d each bring a list of high-flown vocabulary words (<em>dialectic</em>, <em>teleology</em>, <em>juxtapose</em>, <em>ephemeral</em>) and see who could smuggle the most into the discussion.</p><p>You can do the same in more grown-up settings. With patients, for instance, I’ve found it helpful to set small, personal challenges: go sixty seconds without interrupting; earn one sincere laugh; ask about a family member; offer an honest compliment—perhaps admiring the pride a patient takes in her hair routine, even while recovering in a hospital bed. </p><p>These micro-goals don’t cheapen the encounter. On the contrary, they transform routine into curiosity, repetition into presence. From the outside, the interaction may still look like river-stone chatter. But inside, it becomes something else—livelier, warmer, more sincere. After all, conversation, like dancing, becomes far more joyful when you stop trying to dazzle and instead learn to move in time with someone else.</p><h3>Our Advantage</h3><p>Perhaps the clinician best at small talk I’ve ever worked with is a neuroradiologist. In a specialty often deemed first on the chopping block in the age of AI, she offers a strong rebuttal. Patients adore her. She walks them from the waiting room to the CT scanner for lumbar punctures, helps manage their pain, and somehow recalls where they last dined. She trades restaurant tips, remembers birthdays, and focuses wholly on the person beside her. In an age of automation, her attention is an edge no algorithm can match.</p><p>Large language models can churn out progress notes and polite pleasantries faster than any seasoned attending, but they cannot risk embarrassment. That’s where small talk lives: in the fragile charm of a corny joke, a mispronounced name, a candid confession of fatigue. Risk signals sincerity. Until silicon can blush, human clinicians keep our advantage.</p><p>Bateman’s insight is sharp: honest answers would grind polite society to a halt. And in the hospital, we don’t want full confessions at every turn—the work would become unbearable. Instead, we use lightness to feel for the seam, the place where real pain presses through. When we find it, we lift a corner of the burden, just for a moment, then step gently into the next room and the next ritual. We transform this job from mere providers of medical services into a profession and even a vocation.</p><p>In the near future, at 5:45 a.m., I’ll walk into another dim room, note the live weather channel, and begin with “words that mean little but serve much.” Somewhere between the untouched pancakes and the charted potassium, the patient may offer a truth the world outside never hears. That is the paradox we must walk: the emptiest phrases are often the only path to what is full. In the hospital, dancing that path well is not ornament. It is medicine.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080 424w, https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080 848w, https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080 1272w, https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080 1456w" sizes="100vw"><img src="https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080" width="10800" height="7200" data-attrs="{"src":"https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":7200,"width":10800,"resizeWidth":null,"bytes":null,"alt":"man in white button up shirt holding black tablet computer","title":null,"type":"image/jpg","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="man in white button up shirt holding black tablet computer" title="man in white button up shirt holding black tablet computer" srcset="https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080 424w, https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080 848w, https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080 1272w, https://images.unsplash.com/photo-1581056771107-24ca5f033842?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHw0fHxkb2N0b3IlMjBhbmQlMjBwYXRpZW50fGVufDB8fHx8MTc0NTUwODE1NXww&ixlib=rb-4.0.3&q=80&w=1080 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Photo by <a href="true">National Cancer Institute</a> on <a href="https://unsplash.com">Unsplash</a></figcaption></figure></div><div class="subscription-widget-wrap-editor" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe","language":"en"}" data-component-name="SubscribeWidgetToDOM"><div class="subscription-widget show-subscribe"><div class="preamble"><p class="cta-caption">Thanks for reading Space Cadet! 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+ <p>In the hours before dawn, when the rest of the city dreams, I sit with my books cracked open like the skulls they describe. Tables of nerves. Rivers of pathology. The tender machinery of the body laid bare. I am studying for the STEP exams, those trials that guard the gates of medical legitimacy. They demand mastery of disease as taxonomy, the knowledge of what can go wrong in a human life, reduced to lists and patterns.</p><p>Yet the farther I travel into this world of clinical certainties, the more I am struck not by what I know, but by what I remember.</p><p>Today I came to the section on Cerebral Palsy, a condition granted less than a page. Perinatal hypoxia. Spastic diplegia. Intravenous magnesium for fetal neuroprotection. And the peculiar, high-yield pearl: “hand dominance before age one is concerning.” Important information, yes. But to me, it felt like hearing the name of someone I know called out impersonally in a crowded room.</p><p>For the past year, I have worked closely with a young man who lives with cerebral palsy. He is not a bullet point or a vignette. His life cannot be summarized in a mnemonic. He laughs. He labors to speak. He fights, daily, with a quiet strength that no textbook could anticipate. He has become, to me, a teacher.</p><p>When I see him reach across the table or steady himself on uncertain legs, that neurologist’s fact of infant hand preference returns. But now it is alive. Not a detail to be memorized, but a truth I’ve witnessed. This is not knowledge I acquired. It is knowledge that was grafted into me through presence, through story, through love.</p><p>This grafting is the difference between learning and understanding. We speak often of medical knowledge, but too rarely of medical wisdom. Information gathered in sterile rooms without patients can become cold, even arrogant. It risks becoming what the ancients would call <em>gnosis</em>: a knowing that puffs up, not builds up.</p><p>Detached from the person, medicine shrinks.</p><p>When we speak of cerebral palsy, or any diagnosis, without having lived beside it, we may know the shape of the thing but not its weight. We know the neural pathway, but not the toll it takes to re-learn a motion we take for granted. In the absence of the person, our knowledge is hollow. It rings with the tinny resonance of abstraction.</p><p>And so I’ve come to believe that medical education, if it is to be worthy of the name, must always pair study with witness. It must place the textbook beside the bedside. For every correct answer on an exam—displayed, answered, and then forgotten in no more than 90 seconds—there must be a face that lingers in the mind, a story that will not be tidied away.</p><p>The Greeks had a word for the wisdom that grows through experience: <em>phronesis</em>. It is not data. It is not theory. It is moral perception, sharpened by action and humility. We do not test for it, but we know when it is missing.</p><p>I study for STEP because I must. But I study my patients because I need to. They each remind me why any of this matters. And my friend with cerebral palsy reminds me that the body is not a puzzle to be solved but a soul to be tended. That healing is not merely an intervention but a form of presence.</p><p>Let our learning never outpace our reverence.</p><p>Let us not master the body and forget the person.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!dB_L!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!dB_L!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg 424w, https://substackcdn.com/image/fetch/$s_!dB_L!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg 848w, https://substackcdn.com/image/fetch/$s_!dB_L!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!dB_L!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg" width="1456" height="1941" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":1941,"width":1456,"resizeWidth":null,"bytes":3206615,"alt":null,"title":null,"type":"image/jpeg","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/162423754?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!dB_L!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg 424w, https://substackcdn.com/image/fetch/$s_!dB_L!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg 848w, https://substackcdn.com/image/fetch/$s_!dB_L!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!dB_L!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5589e214-f3ce-47d4-b640-42dd47a73ff4_4032x3024.jpeg 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><p></p>

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+ <p>In Greek mythology, gifts from the heavens are never just that. They are tests. They are traps. They are power wrapped in beauty, carrying consequences no mortal can fully foresee. Pandora’s jar. Daedalus’s wings. Ambrosia stolen from Olympus. Each arrives with the promise of elevation with a deadly and divine cost.</p><p>Artificial intelligence is our era’s most seductive offering. It arrives speaking in fluent text, offering insight, speed, and control. It feels, at least at first, divine in its reach. But just like the ancient myths, its promise is entangled with danger. For every improvement it brings, there is a temptation to forget what it replaces, and what it quietly demands in return.</p><div class="subscription-widget-wrap-editor" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe","language":"en"}" data-component-name="SubscribeWidgetToDOM"><div class="subscription-widget show-subscribe"><div class="preamble"><p class="cta-caption">Thanks for reading Space Cadet! Subscribe to learn more about the cutting edge of medicine.</p></div><form class="subscription-widget-subscribe"><input type="email" class="email-input" name="email" placeholder="Type your email…" tabindex="-1"><input type="submit" class="button primary" value="Subscribe"><div class="fake-input-wrapper"><div class="fake-input"></div><div class="fake-button"></div></div></form></div></div><p>Doctors, students, and institutions are already beginning to reshape themselves around these tools. Some do so wisely. Others do so unthinkingly. But Greek myths are not merely quaint allegories. They are blueprints for what happens when humans encounter something too powerful, too soon, and mistake it for a gift with no price.</p><p>What follows is not a rejection of AI. It is a caution. A call for memory. A reflection on what the ancients already knew: that those who accept power without humility may not survive the fall.</p><h2>Pandora and Epimetheus: The Gift Unleashed</h2><p>The first of the Greek myths with clear parallels to our modern condition features one of history’s earliest automatons: Pandora—a lifelike machine, gifted not as a blessing but as a trap to the unsuspecting demigod Epimetheus, by the gods he had unwisely trusted. </p><p>In the myth, Epimetheus (whose name means “hindsight”) fails to heed the warning of his brother Prometheus (“foresight”) and eagerly accepts Pandora, a beautiful creation fashioned by Hephaestus, demanded by Zeus after Prometheus stole fire from the gods. With curiosity untempered by wisdom, Epimetheus opens her infamous jar (deemed today: “Pandora’s Box”), unleashing plagues and curses upon the world and humanity. These evils no one had anticipated. This tale of an unexamined gift resonates with the way artificial intelligence is often rushed into healthcare: introduced without foundational understanding, often because it dazzles rather than solves.</p><p>I’ve worked with AI long before medical school, including a project at NASA involving deep learning and human biometrics. Through that background—and my continued work in medicine—I’ve observed two distinct patterns of adoption. One is Promethean: identifying a problem first, and selecting AI as the most fitting solution. For example, using large language models to transcribe physician notes in the absence of a medical scribe meets a real need. It frees clinicians to focus on patient care while managing the burdens of documentation. The solution fits the elegant and appropriately constrained problem.</p><p>The second, hindsight-driven pattern, imagines AI as a universal solvent: a solution in search of problems. In this mode, artificial intelligence is often deployed not where it's needed, but where it is novel. Sometimes it props up poor study design; other times, it produces long lists of plausible but generic differential diagnoses that offer the illusion of insight without the burden of discernment. If used in these unserious and uncritical ways, doctors risk becoming passive implementers of machine output. Providers of services and technicians in coats rather than stewards of complex, moral, human judgment. We are not just digitizing medical reasoning; we are displacing it.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!Iylj!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!Iylj!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg 424w, https://substackcdn.com/image/fetch/$s_!Iylj!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg 848w, https://substackcdn.com/image/fetch/$s_!Iylj!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!Iylj!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg" width="484" height="704" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":1200,"width":825,"resizeWidth":484,"bytes":null,"alt":"Epimetheus opening Pandora's box, Giulio Bonasone (Italian, active Rome and Bologna, 1531–after 1576), Engraving ","title":null,"type":null,"href":null,"belowTheFold":true,"topImage":false,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="Epimetheus opening Pandora's box, Giulio Bonasone (Italian, active Rome and Bologna, 1531–after 1576), Engraving " title="Epimetheus opening Pandora's box, Giulio Bonasone (Italian, active Rome and Bologna, 1531–after 1576), Engraving " srcset="https://substackcdn.com/image/fetch/$s_!Iylj!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg 424w, https://substackcdn.com/image/fetch/$s_!Iylj!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg 848w, https://substackcdn.com/image/fetch/$s_!Iylj!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!Iylj!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5c660a94-ead7-491d-9338-9ba398142cad_825x1200.jpeg 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Bonasone’s Epimetheus Opening Pandora’s Box</figcaption></figure></div><p>And it raises an unsettling question: what exactly are we trying to eliminate? Are we hoping to automate away the diagnostic work of medicine entirely, leaving physicians to do little more than perform procedures and hold hands? Perhaps this would shorten medical school (a mercy, some might say) but it would also hollow out the very core of the profession. What is left of a doctor who no longer needs to reason, only to reassure? The promise of AI in medicine must not become an excuse to deskill it. If we reduce medicine to the performance of empathy while machines do the thinking, we risk converting physicians into little more than emotionally intelligent interfaces between the algorithm and the patient. That is not a future worth rushing toward.</p><p>I’m now beginning a Master’s of Engineering in AI at Duke. I come with a real-world medical challenge and I hope to address by running the vast data I’ve digitized these past three years through AI. But even in this program I hold my skepticism. AI is seen not as a tool among many, but as a treasure chest. Is it inherently magical, waiting to be unlocked? It’s the same mindset I’ve encountered with the demonstration of new medical devices, where vendor demos elicit wonder but not questions. Like Epimetheus, many are so enamored with the gift that they forget to ask what’s inside the box.</p><p>The danger of accepting such a powerful technology without foresight is that we may unwittingly unleash a swarm of unintended consequences. In medicine, AI algorithms deployed without rigorous testing can introduce hidden biases and unexpected errors. Evils flying out of a digital Pandora’s jar. A model may appear to improve treatment decisions, only to later be discovered performing poorly for minority patients or rare conditions. The foundational training that was skipped in the rollout cannot be easily retrofitted once the damage is done. AI’s probabilistic nature makes it both powerful and difficult to regulate (a topic for our next parable), especially when the systems are opaque even to their creators. It feels, at times, like we’re opening a sealed gadget from Olympus, praying that only miracles come out.</p><p>And yet, the myth of Pandora and Epimetheus reminds us: hope remained in Pandora’s jar. In the context of AI, hope today looks like governance, caution, and humility. With proper foresight, we can mitigate harm and harness the tool wisely and selectively. This means investing in technical training, aligning solutions with real problems, and maintaining healthy skepticism in the face of frictionless adoption. Guardrails (i.e. validation studies, pilot phases, ethical review) are the modern equivalent of keeping the lid half-closed.</p><p>As one expert put it, “Just because a tool is easy to adopt and roll out doesn't mean there isn't an investment on the safety, accuracy and liability side of the coin.” (1) Indeed, it is often the easiest tools that require the most scrutiny. The myth of Pandora is not just about danger; it is about the responsibility of opening what we don’t yet understand.</p><p>The myth of Pandora and Epimetheus reminds us that the danger is not necessarily the technology itself, but the failure to anticipate its consequences. In medicine, we cannot afford to be creatures of afterthought. The practice demands forethought, both technical and moral, if we are to use these gifts wisely.</p><p>But that assumes the technology has no errors, which it most certainly does…</p><h2>Icarus and Daedalus: Hubris and The Fall</h2><p>Among all cautionary tales of human overreach, the legend of Icarus remains one of the most evocative. Icarus’ father Daedalus crafted wings of feather and wax to escape captivity, warning his son not to fly too low, where sea spray might weigh him down, or too high, where the sun could melt the wax. But the thrill of flight overtook Icarus. He soared too close to the sun, and the very tool that lifted him became the instrument of his fall.</p><p>This myth endures because it reveals the danger of trusting a powerful tool without understanding its limits.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!9UFk!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!9UFk!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg 424w, https://substackcdn.com/image/fetch/$s_!9UFk!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg 848w, https://substackcdn.com/image/fetch/$s_!9UFk!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!9UFk!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/e6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg" width="363" height="429.55" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/e6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":1136,"width":960,"resizeWidth":363,"bytes":354519,"alt":"File:Herbert Draper - The Lament for Icarus - Google Art Project.jpg","title":null,"type":"image/jpeg","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="File:Herbert Draper - The Lament for Icarus - Google Art Project.jpg" title="File:Herbert Draper - The Lament for Icarus - Google Art Project.jpg" srcset="https://substackcdn.com/image/fetch/$s_!9UFk!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg 424w, https://substackcdn.com/image/fetch/$s_!9UFk!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg 848w, https://substackcdn.com/image/fetch/$s_!9UFk!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!9UFk!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fe6666223-839d-4f8e-8a14-4b6c47bb00da_960x1136.jpeg 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Herbert Draper’s The Lament for Icarus</figcaption></figure></div><p>During my medical training, I saw a modern version of that first flight. When ChatGPT emerged, it felt like Daedalus’s wings: sophisticated, elegant, empowering. In our first-year clinical problem-solving class (spring 2023), a group of students began feeding cases into the model—always after discussing the case. This is not novel, with over 90% of students in one high-school reporting some usage of the application (2). A middle-aged man with chest pain? The AI suggested myocardial infarction. A young woman with fever and rash? Lupus appeared on the list. For unseasoned students, it seems uncanny. It felt as though there was a super-intelligent colleague who could come to the right answer in 30 seconds when it had taken two-and-a-half hours for first-year medical students.</p><p>So, why not ask the machine when stumped? We can still worked through the problems ourselves, but we can may assume the model’s answer would be there as a safety net.</p><p>This mirrored the broader mood in medicine. GPT-4 had reportedly passed the U.S. Medical Licensing Exam later that year. (3) Articles celebrated the arrival of machine competence. It felt as if the age of flawless digital diagnostics was approaching.</p><p>But there is a clear moment that revealed the fragility beneath the surface.</p><p>We encountered a case involving an older woman under extreme stress who developed chest pain and signs of heart failure. Her coronary angiogram was normal, and the echocardiogram showed apical ballooning. I recognized it as Takotsubo cardiomyopathy (also called “broken heart” syndrome). As I was at odds with the rest of my discussion group, I through the case in the Chatbot hoping to confirm my “zebra diagnosis.” The model insisted it was a standard myocardial infarction and never suggested Takotsubo. Even when prompted again, it repeated its error with confidence.</p><p>At the end of class, when all was said and done it was indeed revealed to be Takotsubo’s.</p><p>Rerunning the same prompt in a different window gave a different answer until I told it was indeed Takotsubo cardiomyopathy, at which point it became obsequious in its agreement with me. This was no glitch. Large language models work probabilistically. They do not produce consistent or grounded truths. They generate what seems likely based on patterns in the data they were trained on. In addition they start spitting out syllables so an early low odds pick will radically shift the rest of their responses. Their answers are fluent, plausible, and often wrong. They are not engines of reasoning. They are mirrors that reflect the data they have absorbed, with no anchor to truth.</p><p>That week, I realized what proverbially flying too high will look like. The model can dazzle with quick wins. But if we had begun to defer to it, trusting the wings more than our own judgment, the wings are not stable. They change, they guess, they hallucinate. If they fail, the fall is ours. This has moral and legal implications.</p><p>This experience is not unique. A study testing GPT-3.5 on 150 clinical vignettes found it was correct less than half the time. (4) The model sounded confident but could not consistently perform on cases requiring nuance. It missed the hard ones and presented errors with the same poise as correct answers. The danger is not just that it is sometimes wrong. It is that it is wrong with such convincing ease.</p><p>For new medical trainees, this is especially hazardous. We are still forming habits of thought. AI lets us skip steps, feel smart, and move faster. But without grounding in the fundamentals, we risk building our practice on shifting sand. One physician told me, “AI could make a good doctor better but a mediocre doctor dangerous.” The good doctor uses it with clarity, understanding what it can and cannot do and eventually never use it again. The mediocre doctor lets the tool think for him, then takes credit for the illusion.</p><p>After the Takotsubo case, I returned to first principles. I studied the condition more closely. I practiced building differentials without assistance. I still use AI to generate study plans each week by providing a helpful outline with my limited time. But I still rely on physical textbooks devoid of screens.</p><p>The myth of Icarus teaches that beauty and brilliance are not enough. I worry that in the coming years, there will be pressure to reduce the number of physicians, citing both the persistent shortage and the supposed sufficiency of AI. Already, one hears whispers in management circles: if a machine can pass Step 1, why train someone for four years to do the same? If it can read an X-ray, why pay for a radiologist?</p><p>We must resist this logic before it becomes policy. We must document where these systems fail, and we must preserve our own competence so that we are not quietly replaced by tools that cannot reason or take responsibility. The risk is not just clinical, it is professional. If we lose the skills of diagnosis and judgment, if we outsource too much to the machine, we will find ourselves left with only the relational labor: comforting patients, delivering news, executing protocols written elsewhere. That is not the practice of medicine. That is something else entirely.</p><p>Mastery of the tool and respect for its constraints are what keep us safe. In medicine, that means understanding how an algorithm works, where it fails, and why it cannot be blindly trusted. The more seamless and intelligent the interface appears, the more dangerous it becomes when mistaken for truth.</p><p>The solution is not to discard the tool, but to remain vigilant. These models will improve. They will sound wiser. They will become deeply embedded in our daily workflows. But we must never forget what they are. They do not think. They do not know. They generate language based on probability, not understanding.</p><p>And when the wings melt, it is not the machine that falls.</p><p>It is us.</p><p>But even if we hold these tools at a distance the gods that give them to us are capricious at best and malevolent at worst….</p><h2>Ambrosia and Tantalus: Divine Temptation and the Eternal Thirst</h2><p>In myth, ambrosia is not simply divine food. It is a substance that set gods apart from mortals. It sustained Olympus, but it did not belong to us mere mortals. Tantalus, who tried to steal that gift and offer it to mankind, was punished not by fire or thunder, but by unfulfilled appetite. He was placed forever in a pool that drained when he bent to drink, and under a tree that pulled its fruit just out of reach. He is not remembered for defiance, but for his torment. An immortal symbol of the danger of longing for something you cannot control. That is where the word “tantalize” comes from.</p><p>Today, we can think of cheap and quick computing as ambrosia. At first glance, chatbots seem like a public good. They promise instant answers, automated tasks, and a flattening of the expertise gap. But these tools are not governed by the public, nor built for the sake of medicine or education. They are the product of private capital, offered freely to build dependence before the price is named. This is not divine benevolence. It is a strategy.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!6I8C!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!6I8C!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg 424w, https://substackcdn.com/image/fetch/$s_!6I8C!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg 848w, https://substackcdn.com/image/fetch/$s_!6I8C!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!6I8C!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg" width="476" height="476" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":750,"width":750,"resizeWidth":476,"bytes":null,"alt":"Sisyphus, Ixion and Tantalus","title":null,"type":null,"href":null,"belowTheFold":true,"topImage":false,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="Sisyphus, Ixion and Tantalus" title="Sisyphus, Ixion and Tantalus" srcset="https://substackcdn.com/image/fetch/$s_!6I8C!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg 424w, https://substackcdn.com/image/fetch/$s_!6I8C!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg 848w, https://substackcdn.com/image/fetch/$s_!6I8C!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!6I8C!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F3feaa424-3b14-4c6a-a3a7-888b6cc1202d_750x750.jpeg 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Roman sarcophagus with three punished Greek figures: Sisyphus (left), Ixion (middle), and Tantalus (right) (as photographed by Dan Diffendale)</figcaption></figure></div><p>Students and institutions have rushed to drink. As mentioned before (See 2), in study halls and clinics, AI is already becoming the first stop for clarification and the last word in uncertainty. And why wouldn’t they? It is faster than a professor, more confident than a textbook, and available at all hours. But this immediate gratification comes at a cost that does not show up on the balance sheet. With each use, we outsource a little more of our agency: our interpretive memory, our confidence in judgment, our ability to wrestle with ambiguity. What begins as convenience becomes reliance.</p><p>The worst trap is not that the machine is merely wrong (causing Icarus to fall). The most ensnaring trap is that it is useful, until it is taken away. These models are not free to produce. (5) Each answer costs compute, each compute cycle costs vast sums of electricity, this electricity requires money, and that money must eventually be recouped. What would happen when an entire generation of physicians and scientists is trained inside a system that expects the oracle to always be there? What happens when it is paywalled, when the interface changes, when the access is tiered? We will not just feel deprived. We will feel lost.</p><p>And this loss is not only intellectual, it is an institutional tragedy. What happens when hospitals eliminate entry-level roles because a chatbot seems to perform the work of a hundred undergraduate scribes looking to get clinical work hours? What happens when research assistants are replaced by autocomplete? These jobs are not just tasks. They are the first rung of professional formation. Remove them, and you don’t just cut costs, you cut futures. We are not just consuming ambrosia. We are displacing labor with something that does not labor at all.</p><p>Worse still, the longer we rely on these tools, the harder it becomes to justify their absence. If a student can pass anatomy with an AI tutor, do they still need a human mentor? If a resident can consult a chatbot integrated in Epic, do they still need a senior to check their thinking? What begins as augmentation turns quietly into substitution, and then into erasure.</p><p>Tantalus shows us that not all hunger leads to growth. Some hungers leave you hollow. Dependency on what we do not govern will not elevate us. It will reduce us, slowly and with our consent. And once we lose the ability to teach, to reason, and to question without permission, it may not return.</p><p>The lesson of ambrosia is not to avoid what is useful, but to remember what it costs. We can drink from the fountain, but only if we remember how to gather water ourselves. We can use the tool, but only if we keep the muscle that once shaped the tool in the first place.</p><p>Because the gods of capital will not always ask before they change the rules. And when they do, we must be ready, not to beg for access, but to build what they took away.</p><h2>Coda: Humanity in the Face of Glittering Gifts</h2><p>In the end, the ancient mythos converge on a timeless truth: when mortals accept gifts from the gods without caution, they often become the playthings of those gods. Today’s “gods” come in the form of powerful algorithms and the wealthy tech companies behind them. Entities that offer us Pandora’s bounties and treasures fresh out of Daedalus’ workshop that are as tantalizing as manna from Heaven. The allure is great. Who wouldn’t want to harness a technology that promises to predict patient outcomes, answer any question, or grant the wisdom of entire medical libraries in seconds? Yet, as we have seen, each myth carries a warning etched in blood and stone.</p><p>From Pandora and Epimetheus, we learn that we must understand and prepare before we embrace a new technology, lest we release a swarm of unintended harms. In practical terms, this means rigorous validation of AI in medicine, ethical oversight, and educating clinicians in both the power and pitfalls of these systems. A modern Prometheus should peek into the box with safety goggles on, and maybe a committee of ethicists and engineers by her side, before throwing the lid wide. Foresight and skepticism are our weapons to keep hope in and evil out.</p><p>From Icarus and Daedalus, the most poignant warning: maintain humility no matter how splendid the innovation. The wings of AI can carry us to great heights to improved diagnostic rates, personalized treatments, streamlined workflows, but we must keep our human intuition and vigilance fully engaged. New doctors should treat AI like an experienced senior advising them, not like a replacement for their own analysis. And when an AI makes an error (as it has and inevitably will), we should respond not with blind faith, but with investigation: understand why it erred, fix the wax in the wings, and learn from it. In short, do not let success delude you into thinking you or your tools are infallible. Medicine has a way of humbling those who grow overconfident, an unexpected case or complication will remind you of the limits of knowledge. AI, for all its brilliance, is part of this unfolding story, not the end of it.</p><p>From Ambrosia and Tantalus, we take the lesson of moderation and self-reliance. The gifts of AI may be sweet, but they are not a substitute for our own skills and judgment. If we indulge without discipline, we risk an eternal thirst, craving the AI’s guidance at every step yet never forming our own decision-making foundations. The capricious providers of these tools can change the game at any moment; we should use AI, yes, but never need for it. In medical education and practice, this will translate to blending AI assistance with traditional learning, always holding the AI’s answers at arms length and continuing to practice the art of medicine without shortcuts. We must treat AI as a consultant, not an oracle: valuable, but not divine.</p><p>As we integrate artificial intelligence into the sacred work of healing and learning, we stand at a crossroads of mythic significance. Down one path, illuminated by the hubris of Icarus’s flight, the greed of Tantalus, and the thoughtlessness of Epimetheus, lies a future where clinicians become dependent, complacent, and ultimately ensnared by the very tools that were meant to empower them. Down the other path, lit by the tempered wisdom of Prometheus, the discipline of wise mentors, and the humility of those who remember their mortality, lies a future where AI is harnessed thoughtfully, a tool like a stethoscope with risks well-managed, a servant and not a master. The difference between these paths is not technology itself but the mindset of those who wield it.</p><p>The gods of capital and computation have indeed handed us glittering gifts. It is up to us mortals to use those gifts without surrendering our agency. In medicine especially, we cannot afford to be playthings of the gods. Our patients are not straw figures on an Olympian game board, and our decisions carry profound weight. We must remain grounded, skeptical, and profoundly human in our approach to AI. Let us cherish curiosity, but not at the expense of foresight; let us enjoy what the gods have given, but not become dependent on their caprice; let us fly high with new tools, but always with an eye on the sun and a mind for the fall. In doing so, we honor the lessons of Pandora, Tantalus, and Icarus and, perhaps, we prove that mortals can learn not to repeat the tragedies of myth.</p><p>In the final analysis, embracing AI in medicine calls for a balance of wonder and caution. We are called to play with the gods’ toys, yes, but on our terms. By weaving ancient wisdom with modern insight, we can accept the gifts of AI without losing our souls or our skills. We can ensure that these tools remain what they should be: servants to our humanity, not the other way around. The myths remind us that the line between help and harm is thin when power is in play. Let us walk that line with eyes open and hearts humble, ever mindful that our calling is to heal as humans— flawed, thinking, caring humans—and no machine, however divine-seeming, can relieve us of that sacred responsibility.</p><p class="button-wrapper" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe now","action":null,"class":null}" data-component-name="ButtonCreateButton"><a class="button primary" href="https://dominictanzillo.substack.com/subscribe?"><span>Subscribe now</span></a></p><p>If you enjoyed this, I’ll recommend a great piece on AI and it’s relations to the <em>Work of Creativity</em> by Oliver Bateman.</p><div class="embedded-post-wrap" data-attrs="{"id":162593590,"url":"https://oliverbatemandoesthework.substack.com/p/the-work-of-creativity","publication_id":1152790,"publication_name":"Oliver Bateman Does the Work","publication_logo_url":"https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fad24b37b-6022-4571-ab5b-ddac41607798_467x467.png","title":"The Work of Creativity","truncated_body_text":"You have seen the creativity seminars. They are everywhere now - in hotel conference rooms, on webinars, in airport bookshops. They promise to unlock your \"unique genius,\" to help you \"think outside the box,\" to teach you the \"seven h…","date":"2025-05-01T06:10:19.730Z","like_count":20,"comment_count":9,"bylines":[{"id":2289209,"name":"Oliver Bateman Does the Work","handle":"oliverbatemandoesthework","previous_name":null,"photo_url":"https://bucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com/public/images/aed21ea5-258a-414d-95d3-6621d8a50954_1813x2755.jpeg","bio":"get some size on you | beloved Pittsburgh-based content creator | columnist for UnHerd + regular contributor to The Ringer, RealClear, Washington Examiner, Men’s Health, and more | ♉ | 700 pound deadlift most of the time ","profile_set_up_at":"2022-10-21T18:34:00.414Z","reader_installed_at":"2022-11-03T21:02:01.384Z","publicationUsers":[{"id":1104999,"user_id":2289209,"publication_id":1152790,"role":"admin","public":true,"is_primary":true,"publication":{"id":1152790,"name":"Oliver Bateman Does the Work","subdomain":"oliverbatemandoesthework","custom_domain":null,"custom_domain_optional":false,"hero_text":"A hub for the work of the Internet's \"King of Content\" covering culture, politics, labor, and athletics with a perspective informed by decades of work in marketing, sales, and the rotted-out carcass of academia. ","logo_url":"https://bucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com/public/images/ad24b37b-6022-4571-ab5b-ddac41607798_467x467.png","author_id":2289209,"primary_user_id":2289209,"theme_var_background_pop":"#FF0000","created_at":"2022-10-21T18:36:38.494Z","email_from_name":null,"copyright":"Oliver Bateman Does the Work","founding_plan_name":"Founding Member","community_enabled":true,"invite_only":false,"payments_state":"enabled","language":null,"explicit":false,"homepage_type":"magaziney","is_personal_mode":false}}],"twitter_screen_name":"MoustacheClubUS","is_guest":false,"bestseller_tier":100}],"utm_campaign":null,"belowTheFold":true,"type":"newsletter","language":"en"}" data-component-name="EmbeddedPostToDOM"><a class="embedded-post" native="true" href="https://oliverbatemandoesthework.substack.com/p/the-work-of-creativity?utm_source=substack&utm_campaign=post_embed&utm_medium=web"><div class="embedded-post-header"><img class="embedded-post-publication-logo" src="https://bucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com/public/images/ad24b37b-6022-4571-ab5b-ddac41607798_467x467.png" loading="lazy"><span class="embedded-post-publication-name">Oliver Bateman Does the Work</span></div><div class="embedded-post-title-wrapper"><div class="embedded-post-title">The Work of Creativity</div></div><div class="embedded-post-body">You have seen the creativity seminars. They are everywhere now - in hotel conference rooms, on webinars, in airport bookshops. They promise to unlock your "unique genius," to help you "think outside the box," to teach you the "seven h…</div><div class="embedded-post-cta-wrapper"><span class="embedded-post-cta">Read more</span></div><div class="embedded-post-meta">7 months ago · 20 likes · 9 comments · Oliver Bateman Does the Work</div></a></div><div><hr></div><p>Sources:</p><ol><li><p>Danny Tobey as quoted by Alexis Kayser in <em>Health AI Is a 'Pandora's Box' of Risk, Lawyer Says. Here's His Advice</em> (<a href="https://www.newsweek.com/health-care-artificial-intelligence-generative-ai-legal-advice-2029149">Newsweek</a>).</p></li><li><p><em>Academic survey on student use of ChatGPT</em> (PDF: <a href="https://studylib.net/doc/27423241/group-5-pr2-final-manuscript#:~:text=possibility%26quot%3B%20of%20using%20ChatGPT%20compared,For%20this%20reason">studylib.net</a>).</p></li><li><p><em>ChatGPT-4 Performance on USMLE Step 1 Style Questions and Its Implications for Medical Education: A Comparative Study Across Systems and Disciplines</em> (Study: <a href="https://pubmed.ncbi.nlm.nih.gov/38510401/">PubMed</a>).</p></li><li><p><em>Performance of ChatGPT on USMLE: Potential for AI-assisted medical education using large language models</em>:<strong> </strong>(Study: <a href="https://journals.plos.org/digitalhealth/article?id=10.1371/journal.pdig.0000198#abstract1">PLOS</a>).</p></li><li><p>Edward Zitron’s <em>There Is No AI Revolution</em>: (<a href="https://www.wheresyoured.at/wheres-the-money/#:~:text=As%20a%20result%20of%20the,any%20other%20generative%20AI%20company">wheresyoured.at</a>).</p></li></ol><p>Links to Art</p><ol><li><p><a href="https://www.metmuseum.org/art/collection/search/392735#:~:text=Title%3A%20Epimetheus%20opening%20Pandora%27s%20box">metmuseum.org</a>; </p></li><li><p><a href="https://commons.wikimedia.org/wiki/File:Herbert_Draper_-_The_Lament_for_Icarus_-_Google_Art_Project.jpg#:~:text=The%20Lament%20for%20Icarus%20%281898%29,Tate%20Britain%2C%20London">commons.wikimedia.org</a>.</p></li><li><p><a href="https://www.worldhistory.org/image/6370/sisyphus-ixion-and-tantalus/#:~:text=A%20Roman%20%20sarcophagus%20showing,%28Vatican%20Museums%2C%20Rome">worldhistory.org</a></p></li></ol><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!B-ql!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!B-ql!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png 424w, https://substackcdn.com/image/fetch/$s_!B-ql!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png 848w, https://substackcdn.com/image/fetch/$s_!B-ql!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png 1272w, https://substackcdn.com/image/fetch/$s_!B-ql!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png" width="1024" height="608" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png","srcNoWatermark":null,"fullscreen":null,"imageSize":"normal","height":608,"width":1024,"resizeWidth":null,"bytes":null,"alt":"","title":null,"type":null,"href":null,"belowTheFold":true,"topImage":false,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" title="" srcset="https://substackcdn.com/image/fetch/$s_!B-ql!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png 424w, https://substackcdn.com/image/fetch/$s_!B-ql!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png 848w, https://substackcdn.com/image/fetch/$s_!B-ql!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png 1272w, https://substackcdn.com/image/fetch/$s_!B-ql!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">AI in medicine as a gift from capricious Greek Gods (sorry for the AI image made curtesy of Substack but it was needed on this post of course).</figcaption></figure></div>

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+ <p>I have been lucky enough to never lose a patient.</p><p>I do not say that lightly. I know too many stories that end otherwise. Somehow, so far, mine haven’t in eight years.</p><p>There have even been moments that felt miraculous. A patient, weathered by years of psychiatric diagnoses and despair, finally responded to treatment. Another, minutes before the neurologist team was set to declare brain dead, took a spontaneous breath. And there was the man whose vena cava ruptured mid-surgery. I was just a student assigned to shadow the case. But I stayed with him and his wife through when I could slip away from my surgery rotation during that week she slept in the ICU. I prayed with her. I sat silently beside her. And, a year later, I was TA’ing for a radiology course. I turned a corner and there he was, walking through the hospital for one-year follow up. He recognized me. We hugged. He remembered my name and told me I’d make a fine doctor one day.</p><p>All of these maybe just short of a miracle (though be assured I did indeed pray). Stories that could have ended in death but none did.</p><p>Before medical school, I worked as an EMT. On my very first day, they handed me a bulletproof vest. I laughed. They didn’t. That was the first clue. I worked with Duke EMS and spent weekends volunteering in Vance County. The calls were chaotic. Sometimes they were dangerous. And always they were fast.</p><p>One night, we picked up a man whose body was beginning to betray him. He was unconscious. His limbs were curling inward. His pupils barely reacted. I started bagging him the moment we reached him and didn’t stop until we rolled into the emergency bay. His oxygen saturation started low, and during one hard turn on the road, it dropped even faster. I didn’t fully understand the physiology at the time. I only knew that when the brain goes too long without air, something irreversible happens. Something shifts. The medic let me give the handoff. As we were loading the stretcher back into the rig, she looked at me and said, If you hadn’t bagged him right, he wouldn’t have made it.</p><p>That stuck with me. So did the training. Our EMT course wasn’t exactly gentle. They threw everything at us including sirens, strobe lights, death metal blasting, and a man in a clown mask shouting in our faces while we practiced compressions, ventilations, and spinal immobilization. In one simulation, an earthquake had supposedly leveled a building. My partner was missing. When I finally found him, they’d turned him into a casualty. I hadn’t noticed. He was a massive firefighter, playing unconscious. When I reached him, he broke character just long enough to wink and ask why I had left him behind.</p><p>The scenarios were contrived, yes. But they were also an invitation. Into something heavier. Into the gravity of it all. I remember one instructor in particular, a gruff Israeli military medic. Toward the end of the course, his voice broke as he told us the number of patients he’d lost because someone applied a tourniquet too late. There was no theatrics in that story. Just a quiet warning. Pay attention. People don’t get do-overs.</p><p>But the closest I came to losing a patient happened before I had even begun formal training. In truth, it was a patient already lost.</p><p>It was a call in Oakland. Fire had arrived just ahead of us. A LUCAS device was already thudding against a man’s chest. He had been diagnosed with stage four throat cancer just a week ago. He lay on the floor in a pool of black bile. His eyes were open. Fixed. But as I stood at the back, gathering history and talking to his wife, I found that they locked on mine, like he was still trying to speak. Still trying to be seen. We worked him for three full rounds of epinephrine. Still no pulses when the LUCAS was paused. The medic made the call.</p><p>He was gone long before we got there. But his wife didn’t know that yet.</p><p>There were more than a dozen of us in the room. Medics. Firefighters. I was just a ride-along. The lowest of the low. But I was the one still talking to her. Gathering his medical history.</p><p>When she was told, she hugged me.</p><p>There were no words from me in that moment.</p><p>That night, my cousin, that paramedic asked me again how I was feeling. She knew, I had lost my father just a month before. Until then I had felt nothing but numb. That night, I didn’t feel numb. I felt sure. Becoming a doctor would mean getting there in time. It would also mean knowing how to stay when we didn’t.</p><p>She confirmed what I already suspected. He was pulseless when we arrived. The machine had been pumping but there was no one left to save. Then she asked me a question I have never been able to forget.</p><p>What if we could have saved him? What if something had gone wrong?</p><p>This is where the silence begins.</p><p>This note started as I typed on my phone while waiting in line for confession. I had nothing to say except the truth. I am heartily sorry. That is what I was there to say. And what I say now.</p><p>I wrote it because, while waiting, I came back to her question. What if we could have saved him? It was not a challenge. It was a kind of mercy. A way of saying, be ready next time.</p><p>So now I think ahead to that future first time. The moment I will have to walk into a quiet room and deliver news no one wants to hear. When we were trying, and there was still some flicker of possibility. And I know what I want to be able to say to the family that we did everything we could. That I did everything I could. Not because it is the right thing to say in a formulaic manner. Because it is the truth.</p><p>I want to have known enough. Practiced enough. Cared enough. So that when the time came, I did not hesitate or let the moment slip past. So that even exhaustion, or grief, or whatever I am carrying that day does not touch the work. Does not dull the edge.</p><p>And maybe that’s something I carry with me. An intensity. A weight. Very well. </p><div><hr></div><p>I have already seen what waits. I saw it in that room. His eyes were open. Fixed. The machine worked his chest in perfect time but the man was already gone. What was left in the room was silence and bile and the long stare of death itself. I met it. I did not turn away.</p><p>Fortune is fickle and I have already been blessed for too long. One day it will come again. I only pray that when it does, I will meet it the same way. Steady. Without fear. Without lying. Without flinching.</p><p>That is the vow. To know enough and care enough that I do not have to speak words I do not believe. To be exacting in my craft and honest in my sorrow.</p><p>I do not ask for perfection. Only that I am not found wanting.</p><p>This is the note I wrote to myself. Amor fati. It is a promise. And perhaps, in time, a prayer.</p><div class="subscription-widget-wrap-editor" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe","language":"en"}" data-component-name="SubscribeWidgetToDOM"><div class="subscription-widget show-subscribe"><div class="preamble"><p class="cta-caption">Subscribe to read more.</p></div><form class="subscription-widget-subscribe"><input type="email" class="email-input" name="email" placeholder="Type your email…" tabindex="-1"><input type="submit" class="button primary" value="Subscribe"><div class="fake-input-wrapper"><div class="fake-input"></div><div class="fake-button"></div></div></form></div></div><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080 424w, https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080 848w, https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080 1272w, https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080 1456w" sizes="100vw"><img src="https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080" width="382" height="254.66666666666666" data-attrs="{"src":"https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":3914,"width":5871,"resizeWidth":382,"bytes":null,"alt":"dextrose hanging on stainless steel IV stand","title":null,"type":"image/jpg","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="dextrose hanging on stainless steel IV stand" title="dextrose hanging on stainless steel IV stand" srcset="https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080 424w, https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080 848w, https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080 1272w, https://images.unsplash.com/photo-1516574187841-cb9cc2ca948b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wzMDAzMzh8MHwxfHNlYXJjaHwzfHxtZWRpY2luZSUyMGJhZCUyMG5ld3N8ZW58MHx8fHwxNzQ3Mzk2OTM4fDA&ixlib=rb-4.1.0&q=80&w=1080 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" 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+ <p>At present, there is a tension. The tension comes from hierarchy,<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-1" href="#footnote-1" target="_self">1</a> and AI is the great solvent of hierarchy. This is my fear: that it will not <em>flatten</em> the world in any naive, egalitarian sense. It will degrade it. It will make high things low, and low things cheaper. The shimmering distinctions that animate human life, those that take decades to form and centuries to refine, will be washed away in weeks by the brute force of a silicon clerk.</p><p>This is not mere speculation. In domains where status and hierarchy <em>matter</em>, where the point is not simply to accomplish a task but to <em>become</em> someone worth accomplishing it, AI will be a cultural Tower of Babel.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!nwVe!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!nwVe!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png 424w, https://substackcdn.com/image/fetch/$s_!nwVe!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png 848w, https://substackcdn.com/image/fetch/$s_!nwVe!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png 1272w, https://substackcdn.com/image/fetch/$s_!nwVe!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/c8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png" width="382" height="382" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/c8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":1024,"width":1024,"resizeWidth":382,"bytes":2078940,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":true,"internalRedirect":"https://dominictanzillo.substack.com/i/165418131?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!nwVe!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png 424w, https://substackcdn.com/image/fetch/$s_!nwVe!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png 848w, https://substackcdn.com/image/fetch/$s_!nwVe!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png 1272w, https://substackcdn.com/image/fetch/$s_!nwVe!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc8a4db97-0e46-4c60-87e9-b8acdacacb9b_1024x1024.png 1456w" sizes="100vw" fetchpriority="high"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Brueger’s Tower of Babel Reimagined as Databases, curtesy of ChatGPT</figcaption></figure></div><p>Domains Affected All Have Matters of Taste, Time, and Hierarchies Embedded:</p><ul><li><p>Art</p></li><li><p>Literature</p></li><li><p>Medicine</p></li><li><p>Law</p></li><li><p>Education</p></li></ul><p>Domains Unaffected Are Those With Short Timer Horizons:</p><ul><li><p>Finance</p></li><li><p>Technology</p></li><li><p>Governance</p></li></ul><p>Finance and tech are not immune to AI, of course. They will adopt and deploy it with zeal. But the hierarchies in these fields (namely: ownership, capital, and networks of influence) are of a harder metal. No LLM will dethrone the Goldman Sachs partner or the CTO of Palantir. If anything, the gap between those who own the machines and those who merely use them will only grow.</p><p>The labor-free techno-utopia some herald<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-2" href="#footnote-2" target="_self">2</a> will resemble nothing so much as a nightmare of late-stage capitalism: a landscape where human striving has been reduced to a thin aesthetic overlay on top of automated extraction machines.</p><p>Let me begin with a simple fact: human lives take decades to unfurl. We are bound in time. We grow. We apprentice. We climb. The becoming is the point. A doctor is not simply a functor that diagnoses disease. She is a person who has <em>become</em> a doctor, through ordeals that shape her mind and soul.</p><p>My thesis (to make it abundantly clear) is that the difficulty of learning and thinking is precisely the point. And to further the point, these machines, as reported in an Apple Paper give the Illusion of Thinking<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-3" href="#footnote-3" target="_self">3</a> and so by surrendering to our thinking capacities to them hastily we will only compromise ourselves.</p><p>For most of human history, technology evolved slowly enough to preserve this cycle of becoming. To make it tangible, on the road to becoming a doctor, new procedures or medicines will come along that have to be integrated within the system of medicine but there was a system stable enough to dedicate a decade of one’s life to enter.</p><p>But today, many of our great institutional structures have already lost this connection. They no longer resemble systems designed to serve human flourishing. Rather, they serve themselves. They are not human-scaled but bureaucratically scaled.</p><p>Consider how insurance has evolved from complement of the modern medical system to its new despot. This was once a human-serving system: to pool risk and pay for medical emergencies. Now insurance is a Kafkaesque labyrinths required for all but navigable only by the semi-initiated. I see this firsthand in explaining American insurance plans to international graduate students. MBA graduates, PhDs, perfectly intelligent people rendered helpless before American paperwork and anachronistic acronyms. If this is their fate, what chance has the domestic poor or otherwise disadvantaged?</p><p>There is an old systems truism: <em>the purpose of a system is what it does.</em> This is not entirely true; it simplifies the world, much like the Great Man theory of history. But its underdetermined nature gives it its explanatory power. The purpose of modern insurance is not to serve customers but to sustain and even engorge itself.</p><p>Why does this happen? Because systems evolve toward local maxima.<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-4" href="#footnote-4" target="_self">4</a> They get stuck. In the topology of possibilities, to move to a globally better system often requires crossing a valley — a temporary dip in performance or profits that no rational actor wishes to endure. Over time, layers of regulation, policy, and institutional inertia turn systems into thickets of local peaks surrounded by deep regulatory chasms.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!tTgM!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!tTgM!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif 424w, https://substackcdn.com/image/fetch/$s_!tTgM!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif 848w, https://substackcdn.com/image/fetch/$s_!tTgM!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif 1272w, https://substackcdn.com/image/fetch/$s_!tTgM!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif" width="758" height="436" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":436,"width":758,"resizeWidth":null,"bytes":34224,"alt":"Lenny Hu — Local vs global maximum","title":null,"type":"image/gif","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="Lenny Hu — Local vs global maximum" title="Lenny Hu — Local vs global maximum" srcset="https://substackcdn.com/image/fetch/$s_!tTgM!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif 424w, https://substackcdn.com/image/fetch/$s_!tTgM!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif 848w, https://substackcdn.com/image/fetch/$s_!tTgM!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif 1272w, https://substackcdn.com/image/fetch/$s_!tTgM!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F61e545ca-9fb6-4c99-bd37-d6688f7103dd_758x436.gif 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><p>Enter my defense of consultants. If you ever wonder why they are paid so much, their utility is precisely acting as modern-day sherpas hired to navigate this ever-shifting topological minefield. The fact that an entire industry exists to decipher systems built by ostensibly rational actors should be an indictment in itself—not of consultants nor of the builders of the systems but of the systems themselves.</p><p>Now here is where AI becomes dangerous. One of its great promises is precisely to <em>paper over</em> this complexity. It can act as a universal lubricant, smoothing the jagged edges of institutional dysfunction. I can ask ChatGPT to explain the differences between insurance plans and ask it to explain to me as if I were five years old to make my decision. So why bother improving insurance at a systems level if we can have an AI Chatbot help everyone pick their best policy? Why reform HR policies when an AI can automate the whole department? Why overhaul the tax code when an AI assistant can file perfectly optimized returns?</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!I1cU!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!I1cU!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png 424w, https://substackcdn.com/image/fetch/$s_!I1cU!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png 848w, https://substackcdn.com/image/fetch/$s_!I1cU!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png 1272w, https://substackcdn.com/image/fetch/$s_!I1cU!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/b52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png" width="1379" height="1380" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/b52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":1380,"width":1379,"resizeWidth":null,"bytes":531386,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/165418131?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F65598231-d48e-43f4-ba7c-d3d13de6b542_1379x1380.png","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!I1cU!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png 424w, https://substackcdn.com/image/fetch/$s_!I1cU!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png 848w, https://substackcdn.com/image/fetch/$s_!I1cU!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png 1272w, https://substackcdn.com/image/fetch/$s_!I1cU!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fb52e9ea4-ad74-4df1-8764-1479c850682d_1379x1380.png 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">My attempt at illustrating AI Mediocrity making total reform both less desirable and less plausible.</figcaption></figure></div><p>At first this sounds wonderful—help me navigate complicated systems to my benefit. But in reality, it is a trap. By patching the visible symptoms of bureaucratic decay, AI will cement that decay into place. Systems that ask to be deconstructed and rebuilt will instead be fossilized under a thin layer of digital competence.</p><p>And here is where the human cost enters. AI will not merely replace rote labor. It will augment much of the <em>middle</em>, the messy strata of human roles that serve as apprenticeships and ladders of social mobility. It can also make those mid-level roles more similar to the further ends, reducing the need or possibility of advancement.</p><p>Consider law. My mother was a legal secretary in her early twenties. She became a lawyer by thirty. What happens when AI can elevate a paralegal to perform 80% of the work of a competent lawyer at 20% of the cost? The entire apprenticeship chain breaks. No more legal secretaries climbing into law school. No more young lawyers earning their scars. You get a hollow profession, and, in short-term, a handful of elite partners directing armies of AI-augmented clerks.</p><p>In medicine, you learn the art of writing notes and distilling a medical story into a succinct gestalt. This skill is not academic. It is crucial. In the emergency department, it is the difference between life and death. In the span of seconds, without clear telemetry or lab values, a physician must decide if a patient is <em>sick</em> or <em>not sick</em>. This is a judgment honed through years of training and practice.</p><p>We may think we are making medical school easier, more kind and forgiving, by teaching students to rely on AI<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-5" href="#footnote-5" target="_self">5</a> assistants to write notes. In doing so, we may be compromising the very quality of the physicians that emerge from the process.</p><p>Worse still, this dissolves one of the natural benefits of the medical hierarchy. Why see an MD or DO in family medicine if she is using the same chat tool as the PA or NP? If the outputs are indistinguishable, the demand for higher pay or greater trust in the MD begins to erode. The distinction itself erodes.</p><p>This is not to denigrate the role of NP. I go to one, because my student insurance covers NPs for primary care appointments. But it begs the question. Is sending someone into a primary care residency today becoming a kind of economic or professional suicide?<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-6" href="#footnote-6" target="_self">6</a> Will medicine be forced to become hyper-specialized, so that there remain houses within the profession where genuine physician expertise is valued and preserved?</p><p>At times I wonder: Am I the stable hand lamenting the invention of the Model-T, fated to watch the horse industry collapse?<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-7" href="#footnote-7" target="_self">7</a> I do not think so. The same pattern I describe will repeat across every vocation I initially highlighted.</p><p>In teaching, you lose the art of constructing a lecture, the slow development of theory of mind that allows a teacher to make clear what is obvious to them but opaque to the student. In the arts, you lose the discipline of sketching badly before sketching well, the very process through which artistic voice emerges. In writing, we automate the process of developing an authorial voice—after all ChatGPT is generally more palatable than most classic poets.<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-8" href="#footnote-8" target="_self">8</a></p><p>But with the great leveler, hierarchies will still remain. However, rather than distinction in the practice of healing they be in the management, finance, and governance of medicine. Ossified, frozen, and brittle. They will be disconnected from the organic process of human growth that once sustained them. This is the pulling of the ladder up where a senior physician will be grandfathered in at his pay-scale but will not grow the practice—only consolidate and shrink its scope.<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-9" href="#footnote-9" target="_self">9</a> It is the conversion of professions into pseudo-mid-level fields where no true masters are formed.</p><p>But a vocation, a genuine calling, should exist in every realm of human endeavor. The fifth amendment caveats (namely physician-patient, attorney-client, and clergy-practitioner privileges) all point to high vocations where one can develop virtue. To become exceptional, and even to become disruptive, one must first embed in, and submit to, a living hierarchy. It is only through this process that one earns the right to transcend it. Without this structure, there is no mastery, and without mastery, there is no excellence worth the name.</p><p>An example I think of that is quintessential to this dynamic is the discovery that <em>Helicobacter pylori</em> is the cause of stomach ulcers. For decades, it was medical wisdom that the stomach was too acidic for bacteria to survive. Ulcers were blamed on stress, diet, and lifestyle, a tidy consensus supported by decades of institutional inertia. But one frustrated and rogue physician, Barry Marshall, kept finding <em>H. pylori</em> in every pathology stain of ulcerated stomach tissue. The notion that bacteria could cause ulcers was treated as heresy.</p><p>Marshall needed to break the field out of its local maximum. So, in an act of clinical audacity, he drank an entire beaker of <em>H. pylori</em>. He soon developed severe gastritis and ulcers. Then he cured himself with antibiotics. The point here is not simply that he was right, but that this act took place not a century ago, but in the 1980s, after fifty years of antibiotic research and usage! The discovery did not emerge from a blank slate, but from a lone voice challenging a deeply <em>stagnant</em> system, one that had optimized itself into a comfortable peak and could no longer see the broader landscape. He won the Nobel Prize for this twenty years later only after the scientific consensus had moved to his theory.<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-10" href="#footnote-10" target="_self">10</a></p><p>And AI will never be on the side of Marshall challenge the status quo. Because it takes inputs and probabilistically guesses based on previous evidence.<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-11" href="#footnote-11" target="_self">11</a> And yet, barring a sharp course correction, it is the future we are rushing toward. AI will not reform bureaucracy. It will entrench it. It will not democratize excellence. It will simulate competence while hollowing out the structures that once produced it. It will never challenge conventional wisdom. It will regurgitate it.</p><div class="captioned-image-container"><figure><a class="image-link image2" target="_blank" href="https://substackcdn.com/image/fetch/$s_!cPID!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!cPID!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg 424w, https://substackcdn.com/image/fetch/$s_!cPID!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg 848w, https://substackcdn.com/image/fetch/$s_!cPID!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!cPID!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg" width="204" height="235.008" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":288,"width":250,"resizeWidth":204,"bytes":null,"alt":null,"title":null,"type":null,"href":null,"belowTheFold":true,"topImage":false,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!cPID!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg 424w, https://substackcdn.com/image/fetch/$s_!cPID!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg 848w, https://substackcdn.com/image/fetch/$s_!cPID!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!cPID!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F48a8929d-544a-481d-bf05-847c144587ea_250x288.jpeg 1456w" sizes="100vw" loading="lazy"></picture><div></div></div></a><figcaption class="image-caption">Barry Marshall, MD</figcaption></figure></div><p>And it will happen not through revolution but through gradualism, a process so incremental that no one is responsible and no one can stop it. Each administrator will shave a few costs, each manager will automate a few tasks, each regulator will allow a few new optimizations. Everyone optimizing for a local maximum never a global one. No one will notice until entire professions have been reduced to a thin managerial elite presiding over vast fields of AI-augmented mediocrity.</p><p>What we need is <em>stewardship</em> within fields; a conscious effort to ensure that AI, if it permitted, is used to augment systems in ways that preserve human becoming. We must ensure that within there remains a ladder worth climbing. That the map of effort still leads somewhere. That young lawyers, doctors, writers, and artists still have reason to strive.</p><p>The word virtue is the Latin version of the concept of Greek <em>arete</em>. <em>Arete</em> means excellence. But if the entire system has made smooth all the jagged points that sincerely allow for growth and eventually excellence.</p><p>Perhaps this is a naive hope. Perhaps asking for global maxima in a world ruled by local optimization is a fool’s errand. A video game analogy is apt: every hour spent grinding for short-term pleasure trades away the possibility of higher peaks of meaning.</p><p>What we are getting wrong<a class="footnote-anchor" data-component-name="FootnoteAnchorToDOM" id="footnote-anchor-12" href="#footnote-12" target="_self">12</a> is to deploy these tools eagerly, treating every difficulty as a problem in need of a solution. Not every friction is bad. Often, it is the friction itself that forms the soul. Without difficulty, there is no shaping force. Without struggle, there is no virtue. We must preserve a space where genuine excellence, <em>arete</em> and virtue, can still emerge. The long ladders of mastery must remain intact, with real heights worth striving toward. Otherwise, we are not optimizing the human condition. We are flattening it.</p><p>This is why hierarchy matters. Not for its own sake, but because it is the scaffold on which excellence is built. The alternative is clear. If we allow ourselves to automate away the processes by which humans become fully formed, we will not build a stairway to heaven. We will build a tower. And if the Genesis story is illustrative, it will fall, scattering us to the winds.</p><div class="digest-post-embed" data-attrs="{"nodeId":"fbdaae09-dccd-4bef-8945-9c8cc593d669","caption":"In Greek mythology, gifts from the heavens are never just that. They are tests. They are traps. They are power wrapped in beauty, carrying consequences no mortal can fully foresee. Pandora’s jar. Daedalus’s wings. Ambrosia stolen from Olympus. Each arrives with the promise of elevation with a deadly and divine cost.","cta":"Read full story","showBylines":true,"size":"lg","isEditorNode":true,"title":"Playthings of the Gods: AI in Medicine","publishedBylines":[{"id":111458144,"name":"Dominic Tanzillo","bio":"Space Cadet and Medical Student. Notes from the hospital and reflections on limits. See you space cowboy...","photo_url":"https://substack-post-media.s3.amazonaws.com/public/images/745a24ad-3cc9-4ebd-a4fc-a3f3b0c91719_1170x1170.jpeg","is_guest":false,"bestseller_tier":null}],"post_date":"2025-05-09T14:01:14.406Z","cover_image":"https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F89fb78d2-5170-4492-8c7d-4671e257c660_1024x608.png","cover_image_alt":null,"canonical_url":"https://dominictanzillo.substack.com/p/playthings-of-the-gods-ai-in-medicine","section_name":null,"video_upload_id":null,"id":163146048,"type":"newsletter","reaction_count":8,"comment_count":6,"publication_id":null,"publication_name":"Space Cadet","publication_logo_url":"https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4ff6c46a-5bdd-4075-952b-07c5a422552f_1080x1080.png","belowTheFold":true}"></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-1" href="#footnote-anchor-1" class="footnote-number" contenteditable="false" target="_self">1</a><div class="footnote-content"><p>Substitute: Hierarchy for Chain of Command if that is more palatable</p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-2" href="#footnote-anchor-2" class="footnote-number" contenteditable="false" target="_self">2</a><div class="footnote-content"><p>https://finance.yahoo.com/news/bill-gates-wants-tax-robots-233045575.html</p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-3" href="#footnote-anchor-3" class="footnote-number" contenteditable="false" target="_self">3</a><div class="footnote-content"><p>https://machinelearning.apple.com/research/illusion-of-thinking</p><p></p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-4" href="#footnote-anchor-4" class="footnote-number" contenteditable="false" target="_self">4</a><div class="footnote-content"><p>Image and mathematical thinking analogy: https://www.lennyhu.com/post/179991559076/local-vs-global-maximum</p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-5" href="#footnote-anchor-5" class="footnote-number" contenteditable="false" target="_self">5</a><div class="footnote-content"><p>https://vocal.media/journal/bill-gates-predicts-ai-will-replace-doctors-and-teachers-within-10-years-but-humans-still-have-a-role</p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-6" href="#footnote-anchor-6" class="footnote-number" contenteditable="false" target="_self">6</a><div class="footnote-content"><p>https://journalofethics.ama-assn.org/article/educational-debt-and-specialty-choice/2013-07</p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-7" href="#footnote-anchor-7" class="footnote-number" contenteditable="false" target="_self">7</a><div class="footnote-content"><p>Analogy borrowed from the Sheriff of Sodium who speaks powerfully on this subject:</p><div id="youtube2-kALDN4zIBT0" class="youtube-wrap" data-attrs="{"videoId":"kALDN4zIBT0","startTime":null,"endTime":null}" data-component-name="Youtube2ToDOM"><div class="youtube-inner"><iframe src="https://www.youtube-nocookie.com/embed/kALDN4zIBT0?rel=0&autoplay=0&showinfo=0&enablejsapi=0" frameborder="0" loading="lazy" gesture="media" allow="autoplay; fullscreen" allowautoplay="true" allowfullscreen="true" width="728" height="409"></iframe></div></div></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-8" href="#footnote-anchor-8" class="footnote-number" contenteditable="false" target="_self">8</a><div class="footnote-content"><p>https://www.scimex.org/newsfeed/shakespeare-or-chatgpt-people-prefer-ai-over-real-classic-poetry</p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-9" href="#footnote-anchor-9" class="footnote-number" contenteditable="false" target="_self">9</a><div class="footnote-content"><p>https://www.cnbc.com/2023/02/22/amazon-closes-deal-to-buy-primary-care-provider-one-medical.html</p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-10" href="#footnote-anchor-10" class="footnote-number" contenteditable="false" target="_self">10</a><div class="footnote-content"><p>https://www.mayoclinicproceedings.org/article/S0025-6196(16)30032-5/fulltext</p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-11" href="#footnote-anchor-11" class="footnote-number" contenteditable="false" target="_self">11</a><div class="footnote-content"><p>Maybe deep learning will hold a way out and maybe neural networks will one day emulate a full human mind with intuition and even deviance. I doubt it and especially in the short term when they might be massed deployed.</p></div></div><div class="footnote" data-component-name="FootnoteToDOM"><a id="footnote-12" href="#footnote-anchor-12" class="footnote-number" contenteditable="false" target="_self">12</a><div class="footnote-content"><p>(to burry the lead)</p></div></div>

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1	+ <p>In artificial</p>

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+ <p>The human body was built for Earth. Gravity shapes our bones, blood, and balance. But when a rocket launches people into orbit, all of those systems face stress they were never designed to handle. Space travel is often framed in terms of rockets and technology, yet the biggest challenge may be biological: keeping astronauts healthy on journeys that stretch weeks, months, or even years.</p><p>To glimpse how spaceflight affects the body, NASA (in conjunction with Space X and Cornell Medical School) released blood chemistry data from the Inspiration4 mission, the first all-civilian orbital flight. By studying biomarkers like liver enzymes, inflammatory proteins, and electrolyte balance, we can see how the body responds to launch, microgravity, and return to Earth. Though the mission lasted only three days, the blood of its four crew members tells a story of stress, adaptation, and recovery that holds lessons for future space exploration.</p><p>This post is written for curious readers rather than medical specialists. If you are a student, a space enthusiast, or simply someone fascinated by the limits of the human body, this story is for you. Space exploration is often framed in terms of rockets, propulsion, and engineering breakthroughs, but astronauts remind us that biology is just as central. The future of spaceflight depends not only on how far our machines can travel, but on how well our bodies can endure the journey.</p><h2>How Do We Get Samples From People Who Have Been to Space?</h2><p>The analysis presented here draws on the Inspiration4 biomarker dataset, released publicly by NASA. It contains blood chemistry and cardiovascular markers collected before, during, and after the three-day orbital mission. These markers include familiar clinical measures, such as liver enzymes, inflammatory proteins, and electrolyte levels, the same kinds of tests a doctor might order on Earth, but taken just before and after the extraordinary context of space.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!upY7!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!upY7!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg 424w, https://substackcdn.com/image/fetch/$s_!upY7!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg 848w, https://substackcdn.com/image/fetch/$s_!upY7!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!upY7!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg" width="1456" height="971" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":971,"width":1456,"resizeWidth":null,"bytes":null,"alt":"SpaceX Launch: How the Inspiration4 Crew Trained for Their Flight? - The New York Times","title":null,"type":null,"href":null,"belowTheFold":false,"topImage":true,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="SpaceX Launch: How the Inspiration4 Crew Trained for Their Flight? - The New York Times" title="SpaceX Launch: How the Inspiration4 Crew Trained for Their Flight? - The New York Times" srcset="https://substackcdn.com/image/fetch/$s_!upY7!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg 424w, https://substackcdn.com/image/fetch/$s_!upY7!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg 848w, https://substackcdn.com/image/fetch/$s_!upY7!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg 1272w, https://substackcdn.com/image/fetch/$s_!upY7!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0979534b-1b84-421f-9a4b-147abf04ff33_2048x1366.jpeg 1456w" sizes="100vw" fetchpriority="high"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a><figcaption class="image-caption">Inspiration4 Commercial Astronauts. From left to right: Jared Isaacman, Sian Proctor, Hayley Arcenaeux, and Christopher Sembroski Courtesy of the <a href="https://www.nytimes.com/2021/09/15/science/spacex-launch-crew-training.html">New York Times</a>. </figcaption></figure></div><p>Our astronauts flew aboard a Falcon 9 rocket on the 55th Anniversary of the Gemini Flight. Four specially trained American astronauts, two men and two women: Commander Jared Isaacman, Pilot Sian Proctor, Medical Officer, Hayley Arceneaux, and Payload Specialist Christopher Sembroski flew for three days.</p><p>As part of the commercial contract (and SpaceX / NASA’s larger efforts) they offered their biometric data as part of the longitudinal <a href="https://www.nasa.gov/hrp/">Human Research Program (HRP) at NASA</a>. This means that, while anonymized, their data is shared for the benefit of researchers who wish to conduct independent research. </p><p>Christopher Mason, manages all of these samples and has worked with Duke to analyze and understand these data in the larger <a href="https://soma.weill.cornell.edu/">Space Omics and Medical Atlas</a>. These efforts illustrate that humanity is collectively working on open-source and collaborative data exploration to understand just how we might react to space. These samples are incredibly precious and accordingly, must be treated with particular reverence to not hide them away behind closed doors.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!HAY3!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!HAY3!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png 424w, https://substackcdn.com/image/fetch/$s_!HAY3!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png 848w, https://substackcdn.com/image/fetch/$s_!HAY3!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png 1272w, https://substackcdn.com/image/fetch/$s_!HAY3!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/eedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png" width="1456" height="593" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/eedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":593,"width":1456,"resizeWidth":null,"bytes":1646894,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/174889396?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!HAY3!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png 424w, https://substackcdn.com/image/fetch/$s_!HAY3!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png 848w, https://substackcdn.com/image/fetch/$s_!HAY3!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png 1272w, https://substackcdn.com/image/fetch/$s_!HAY3!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Feedce20e-81eb-4dbf-bfac-c21db60294fe_1899x773.png 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><h2>Data Pipeline</h2><p>To make sense of the data, several steps were necessary. Not only that you can do it yourself courtesy of our <a href="https://github.com/DominicTanzillo/Inspiration-Health-Data/blob/main/writeup.ipynb">public GitHub</a> and <a href="https://huggingface.co/spaces/DTanzillo/Inspiration-Health-Data">application</a>. First, we cleaned the dataset available on <a href="https://osdr.nasa.gov/bio/repo/data/studies/OSD-575">NASA’s website</a> by removing incomplete or inconsistent measures. Importantly we have to find outliers and consider how to interpret them. For example, liver enzymes are quite variable within a person and, accordingly, we have to consider when outliers may occur in our metabolic panel. In one astronaut their liver enzymes immediately post-flight and long after flight are significant outliers from the rest of their baseline data. This is actually exactly what we want to see! That space produced a considerable shift in the healthy functioning of the liver (more activity means the liver is working harder) suggests there is a metabolic insult incurred in space transit.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!LF1c!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!LF1c!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png 424w, https://substackcdn.com/image/fetch/$s_!LF1c!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png 848w, https://substackcdn.com/image/fetch/$s_!LF1c!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png 1272w, https://substackcdn.com/image/fetch/$s_!LF1c!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png" width="490" height="413" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":413,"width":490,"resizeWidth":null,"bytes":17289,"alt":"","title":null,"type":"image/png","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/174889396?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" title="" srcset="https://substackcdn.com/image/fetch/$s_!LF1c!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png 424w, https://substackcdn.com/image/fetch/$s_!LF1c!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png 848w, https://substackcdn.com/image/fetch/$s_!LF1c!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png 1272w, https://substackcdn.com/image/fetch/$s_!LF1c!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F019f9f94-b53b-4719-acb5-06a5f8b876a4_490x413.png 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><p>Then, we engineered new features to capture patterns not directly reported. One example is the Anion Gap, a standard clinical calculation that tracks shifts in electrolyte balance. On Earth, doctors use it to monitor conditions like dehydration or metabolic stress. In orbit, it provides a window into how spaceflight affects fluid and chemical balance inside the body. In particular, we could see if changes in sodium, potassium and other electrolytes trended together (no significant shifts) or if some of these changes occurred at different rates indicating troubles with respiration or liver function. Taken in aggregate we can consider the health of our astronauts as if we are a doctor monitoring the vitals of a patient in the hospital.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!w-Xe!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!w-Xe!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png 424w, https://substackcdn.com/image/fetch/$s_!w-Xe!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png 848w, https://substackcdn.com/image/fetch/$s_!w-Xe!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png 1272w, https://substackcdn.com/image/fetch/$s_!w-Xe!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/d29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png" width="790" height="590" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/d29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":590,"width":790,"resizeWidth":null,"bytes":66373,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/174889396?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!w-Xe!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png 424w, https://substackcdn.com/image/fetch/$s_!w-Xe!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png 848w, https://substackcdn.com/image/fetch/$s_!w-Xe!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png 1272w, https://substackcdn.com/image/fetch/$s_!w-Xe!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd29e7142-3f98-4ab1-8068-65b9707c8bb3_790x590.png 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><h2>Visualization and Stats!</h2><p>As with any type of data, we first have to do some preliminary exploration to see what we’re even looking at. This occurred in parallel with the aforementioned pipeline. However, there is a strategy in fine tuning this data. Take fibrinogen for example. This marker detects when blood clots are being formed in the human body and is actually decreased when the liver is working on other projects to keep the body healthy. Accordingly, if we can find a shift from baseline (defined in the time window before flight), we can gain insight into the liver function as well as risk of having a severe blood clot in the astronaut co-hort. And conducting a student’s t-test we found just that in 3 of our four astronauts!</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!6yqh!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!6yqh!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png 424w, https://substackcdn.com/image/fetch/$s_!6yqh!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png 848w, https://substackcdn.com/image/fetch/$s_!6yqh!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png 1272w, https://substackcdn.com/image/fetch/$s_!6yqh!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/d161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png" width="755" height="462" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/d161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":462,"width":755,"resizeWidth":null,"bytes":55011,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/174889396?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!6yqh!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png 424w, https://substackcdn.com/image/fetch/$s_!6yqh!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png 848w, https://substackcdn.com/image/fetch/$s_!6yqh!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png 1272w, https://substackcdn.com/image/fetch/$s_!6yqh!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd161048c-249f-43e9-a59b-bfcef3ddca17_755x462.png 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><p>You’ll note that these updated figures look slightly differently. We have our ranges considered normal for each astronaut that stem from our original pre-launch samples. Because the Inspiration4 mission was short and each astronaut’s sampling schedule was slightly different, we created a “stretched” flight timeline. This allowed us to align measurements across individuals, making it easier to compare patterns and visualize how the body changes over the course of a spaceflight. We had to artificially pretend the flight was 30 days to get this effect but the graphs are much cleaner.</p><h2>Trends</h2><p>For our direct liver enzymes we tested compared our fibrinogen samples against ALT and AST (measures of how hard the liver is working).</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!qevI!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!qevI!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png 424w, https://substackcdn.com/image/fetch/$s_!qevI!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png 848w, https://substackcdn.com/image/fetch/$s_!qevI!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png 1272w, https://substackcdn.com/image/fetch/$s_!qevI!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png" width="716" height="449" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":449,"width":716,"resizeWidth":null,"bytes":38734,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/174889396?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!qevI!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png 424w, https://substackcdn.com/image/fetch/$s_!qevI!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png 848w, https://substackcdn.com/image/fetch/$s_!qevI!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png 1272w, https://substackcdn.com/image/fetch/$s_!qevI!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dd30a89-8c5c-4228-8325-c9eb58b320fe_716x449.png 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!JMn3!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!JMn3!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png 424w, https://substackcdn.com/image/fetch/$s_!JMn3!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png 848w, https://substackcdn.com/image/fetch/$s_!JMn3!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png 1272w, https://substackcdn.com/image/fetch/$s_!JMn3!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png" width="742" height="446" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":446,"width":742,"resizeWidth":null,"bytes":45243,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/174889396?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!JMn3!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png 424w, https://substackcdn.com/image/fetch/$s_!JMn3!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png 848w, https://substackcdn.com/image/fetch/$s_!JMn3!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png 1272w, https://substackcdn.com/image/fetch/$s_!JMn3!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F2da25163-f381-4dd3-ba20-6833ce1b8a09_742x446.png 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><p>You’ll note that across all four astronauts ALT showed significant deviations while AST did in just three. You’ll note that in one astronaut (C004) the AST ranges shifted outside of what is classically considered the healthy limits of the liver (green dotted line). Eureka, there’s a huge finding. Space is actually harmful to human liver with even just three-days in space showing significant variance.</p><p>And even in pockets without unique individual differences we can visualize general trends. Sodium in the blood corresponds roughly with levels of hydration. Taken in aggregate we can see that after just three days in space, everyone’s sodium declined. Even if appetites slow down because of space-flight adaptation syndrome the kidneys keep functioning.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!gIhG!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!gIhG!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png 424w, https://substackcdn.com/image/fetch/$s_!gIhG!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png 848w, https://substackcdn.com/image/fetch/$s_!gIhG!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png 1272w, https://substackcdn.com/image/fetch/$s_!gIhG!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png" width="734" height="436" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":436,"width":734,"resizeWidth":null,"bytes":35998,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":true,"topImage":false,"internalRedirect":"https://dominictanzillo.substack.com/i/174889396?img=https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png","isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!gIhG!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png 424w, https://substackcdn.com/image/fetch/$s_!gIhG!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png 848w, https://substackcdn.com/image/fetch/$s_!gIhG!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png 1272w, https://substackcdn.com/image/fetch/$s_!gIhG!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F7730ce4d-4204-4ca6-ace6-db53d32d4da7_734x436.png 1456w" sizes="100vw" loading="lazy"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><h3>The Gender Potassium Gap</h3><p>Perhaps most interestingly is that our data here allowed us to visualize that potassium levels significantly decreased significantly only in our female astronauts.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!4s6C!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc517a6d5-1637-4b15-842d-156c82741857_718x460.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!4s6C!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc517a6d5-1637-4b15-842d-156c82741857_718x460.png 424w, https://substackcdn.com/image/fetch/$s_!4s6C!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fc517a6d5-1637-4b15-842d-156c82741857_718x460.png 848w, 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fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><p>As personalized medicine grows, this raised the question if astronauts should have customized meal plans and diet regimens based on their unique biology.</p><h2>Discussion</h2><h3>Ethics</h3><p>The use of biomedical data from spaceflight presents a complex set of ethical challenges that extend beyond standard clinical research. Although the dataset from the Inspiration4 mission is anonymized, true anonymity is difficult to preserve given that the identities of the four crew members are public knowledge. This creates a heightened risk of re-identification and underscores the need for careful stewardship of data that cannot be fully disentangled from the individuals who provided it.</p><p>Participation in human spaceflight often requires astronauts to relinquish significant aspects of medical privacy. Such consent, while voluntary, is not without ethical tension. Astronauts may feel professional, contractual, or patriotic obligations that complicate the notion of free choice. This context obliges researchers and communicators to treat the resulting data with particular sensitivity, recognizing that its availability is not simply a product of neutral scientific practice but of personal sacrifice.</p><p>The value of open science further complicates these issues. Public access to astronaut biomarker data enables independent research, democratizes knowledge production, and fosters innovation. At the same time, openness increases the likelihood that data may be misused, sensationalized, or taken out of context. The ethical imperative, therefore, is not to restrict access but to cultivate responsible practices of curation, interpretation, and communication that balance the benefits of transparency with the dignity and autonomy of research participants.</p><h3>Limitations of a Small Sample</h3><p>Another concern lies in the interpretation and communication of findings. A dataset of four individuals cannot support sweeping conclusions, yet its novelty and symbolic significance invite overstatement. The ethical responsibility here is twofold: to present analyses with transparency about their limitations and to resist the temptation to frame preliminary signals as definitive evidence. Overinterpretation risks not only misleading the public but also shaping future policies and medical protocols on an insufficient evidentiary basis.</p><p>Finally, equity must be considered in the longer horizon of human spaceflight research. As commercial missions expand participation beyond career astronauts, questions arise regarding who is asked to provide biomedical data, under what terms, and for whose benefit. Ensuring that contributions to collective scientific knowledge do not disproportionately burden or exploit participants is a central ethical requirement for the emerging era of civilian space exploration.</p><h3>Bias</h3><p>Beyond the constraints of sample size, bias poses another significant challenge in interpreting biomedical data from spaceflight. The Inspiration4 mission involved four individuals who were all healthy, well-screened, and highly motivated to participate in a historic endeavor. Their physiological responses may not reflect those of a broader or more diverse population. This raises concerns about generalizability: findings drawn from such a select group may reinforce assumptions that do not hold for individuals with different health profiles, ages, or genetic backgrounds.</p><p>Selection bias is particularly relevant in commercial spaceflight, where access is often limited to individuals with financial means or institutional support. As a result, the biomedical knowledge generated may disproportionately reflect the physiology of certain demographic groups, leaving other populations underrepresented in the emerging space medicine literature. Similarly, gender differences, which the Inspiration4 dataset already hints at in relation to potassium regulation, may be overlooked or minimized when male-dominated samples are treated as normative.</p><p>Analytical bias must also be considered. The act of cleaning, normalizing, and stretching timelines introduces interpretive choices that can shape outcomes in subtle but consequential ways. Even well-intentioned statistical adjustments may inadvertently exaggerate or obscure patterns. Transparency about these methodological decisions is therefore essential to ensure that findings are not artifacts of data processing.</p><p>Addressing these biases requires deliberate strategies: recruiting more heterogeneous participants as commercial access expands, developing analytical methods that foreground variability rather than averages, and embedding reflexivity in how researchers interpret limited data. Recognizing and mitigating bias is crucial not only for the validity of scientific conclusions but also for ensuring that the benefits of space medicine extend equitably to all who may one day travel beyond Earth.</p><h2>Biggest Take Aways</h2><p>The Inspiration4 dataset, although limited in scale, provides an unusually vivid view of how quickly and significantly spaceflight can alter human physiology. The clearest message is that even a three-day mission is sufficient to produce measurable changes in liver enzymes, inflammatory proteins, and electrolyte balance. Space is therefore not only an unfamiliar environment but one that actively challenges the stability of fundamental biological systems.</p><p>Several findings were particularly unexpected. One of the most striking was the gender-specific decline in potassium, which appeared only in the female astronauts. This observation raises important questions about how diet, metabolism, or hormonal regulation may interact differently with microgravity, and it suggests that future missions may require individualized nutritional or medical strategies.</p><p>Another surprise was the degree of stress observed in liver function. Shifts in enzymes such as ALT and AST indicated that the liver was working harder than normal even during such a short period in orbit. This finding challenges the common assumption that biomedical risks accumulate only during longer missions and instead shows that spaceflight can place strain on the body almost immediately.</p><p>Finally, the consistent decline in sodium levels across all crew members highlighted how fluid and hydration balance is disrupted in space. While reduced appetite and altered kidney function have long been reported by astronauts, the clear biochemical signal of these changes reinforces how tightly linked and vulnerable these processes are.</p><p>Taken together, the results suggest that adaptation to space is both rapid and variable. Certain effects, such as sodium loss, appear broadly shared, while others, such as potassium regulation, reveal differences linked to individual biology. The larger lesson is that preparing for longer and more diverse missions will depend not only on advances in engineering but also on a deeper understanding of how to protect a body that evolved to thrive under Earth’s gravity.</p><h2>Interactive</h2><p>You can access and play with all of these graphs here: <a href="https://huggingface.co/spaces/DTanzillo/Inspiration-Health-Data">Interactive App</a></p>

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+ <p>Hospitals and health startups face a paradox. They need massive, diverse datasets to innovate responsibly, yet regulations such as HIPAA and GDPR restrict how that data can be shared and analyzed. Synthetic data promises a solution by generating realistic, non-identifiable data that mimics patient populations without exposing personal records. But without clear governance, the same technology could replicate the inequities it aims to eliminate.</p><p>In the realm of artificial intelligence, many algorithms are trained in an evolutionary manner. These models improve through iterative feedback, much like natural selection rewards successful adaptations. Companies developing these systems often adopt a similar mindset: optimizing for growth, market share, and data acquisition. For both models and corporations, success depends on access to resources. In this context, those resources are data, whether drawn from users directly or simulated through advanced modeling. In hospitals, that means patient information—both clinical records protected under HIPAA and broader “alternative data” generated through patients’ interactions in the digital economy.</p><p>Alternative data refers to information that falls outside traditional medical charts and may not be safeguarded under existing privacy laws. In many cases, such data is critical for operations. As an example offered by <a href="https://masters.pratt.duke.edu/news/dr-pramod-singh-joins-duke-ai-master-of-engineering-faculty/">Dr. Pramod Singh</a>, in the unfortunate scenario of a mass casualty incident, population density metrics and hospital bed availability data can guide first responders and optimize emergency resource distribution. However, when the use of alternative data extends to financial profiling or patient screening, the ethical boundaries become blurred. Data intended to improve public health could just as easily be repurposed to limit access to care.</p><div class="captioned-image-container"><figure><a class="image-link image2 is-viewable-img" target="_blank" href="https://substackcdn.com/image/fetch/$s_!3oQO!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png" data-component-name="Image2ToDOM"><div class="image2-inset"><picture><source type="image/webp" srcset="https://substackcdn.com/image/fetch/$s_!3oQO!,w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png 424w, https://substackcdn.com/image/fetch/$s_!3oQO!,w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png 848w, https://substackcdn.com/image/fetch/$s_!3oQO!,w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png 1272w, https://substackcdn.com/image/fetch/$s_!3oQO!,w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png 1456w" sizes="100vw"><img src="https://substack-post-media.s3.amazonaws.com/public/images/d00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png" width="1024" height="608" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/d00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png","srcNoWatermark":null,"fullscreen":null,"imageSize":"normal","height":608,"width":1024,"resizeWidth":null,"bytes":null,"alt":null,"title":null,"type":null,"href":null,"belowTheFold":false,"topImage":true,"internalRedirect":null,"isProcessing":false,"align":null,"offset":false}" class="sizing-normal" alt="" srcset="https://substackcdn.com/image/fetch/$s_!3oQO!,w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png 424w, https://substackcdn.com/image/fetch/$s_!3oQO!,w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png 848w, https://substackcdn.com/image/fetch/$s_!3oQO!,w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png 1272w, https://substackcdn.com/image/fetch/$s_!3oQO!,w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd00d7b79-bdf6-493c-9a9a-af9049a3b2b0_1024x608.png 1456w" sizes="100vw" fetchpriority="high"></picture><div class="image-link-expand"><div class="pencraft pc-display-flex pc-gap-8 pc-reset"><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container restack-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-refresh-cw"><path d="M3 12a9 9 0 0 1 9-9 9.75 9.75 0 0 1 6.74 2.74L21 8"></path><path d="M21 3v5h-5"></path><path d="M21 12a9 9 0 0 1-9 9 9.75 9.75 0 0 1-6.74-2.74L3 16"></path><path d="M8 16H3v5"></path></svg></button><button tabindex="0" type="button" class="pencraft pc-reset pencraft icon-container view-image"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="lucide lucide-maximize2 lucide-maximize-2"><polyline points="15 3 21 3 21 9"></polyline><polyline points="9 21 3 21 3 15"></polyline><line x1="21" x2="14" y1="3" y2="10"></line><line x1="3" x2="10" y1="21" y2="14"></line></svg></button></div></div></div></a></figure></div><p>Synthetic data sits at the intersection of these opportunities and risks. Unlike anonymized datasets, synthetic data does not originate from identifiable individuals but is generated by statistical or machine learning models that simulate real-world patterns. This innovation enables researchers and practitioners to analyze realistic datasets without breaching patient confidentiality. Hospitals can test algorithms for sepsis detection or model the effects of bed shortages using synthetic patient records. In global collaborations, synthetic data allows institutions to share research insights without transferring identifiable information, maintaining compliance with privacy regulations like HIPAA in the United States or GDPR in the European Union.</p><p>Yet synthetic data introduces its own challenges. Studies such as <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC10562365/">Giuffrè and Shung (2023)</a> emphasize that synthetic data cannot be assumed risk-free simply because it lacks direct identifiers. If the underlying models reproduce rare or unique characteristics, they can inadvertently enable re-identification when combined with external data sources. Moreover, biases embedded in the original datasets often carry over into their synthetic counterparts. If real-world data underrepresents certain populations, synthetic data will reinforce those disparities, potentially concealing bias beneath a veneer of statistical neutrality.</p><p>There is also the danger of “function creep,” where datasets or tools designed for one purpose migrate into ethically questionable uses. The same synthetic data that improves emergency response could, if paired with financial data, be used to predict a patient’s likelihood of payment or long-term profitability. This practice would conflict directly with the principles of beneficence and justice that underpin both medicine and responsible business practice. The ethical risk lies not only in the data itself but in the evolving incentive structures of the organizations that use it.</p><p>To ensure that synthetic data advances health equity rather than undermines it, stakeholders must look beyond technical accuracy and adopt a robust ethical framework. This framework should require transparency in how synthetic data is produced, explicit definition of its intended uses, and governance mechanisms that prevent repurposing for discriminatory or profit-driven goals. Regulatory agencies may also need to extend privacy protections to synthetic and alternative data, particularly as the distinction between “real” and “artificial” information grows increasingly porous.</p><p>The broader evolutionary metaphor remains instructive. Just as evolutionary algorithms optimize within their environments, corporations optimize for competitive advantage. The rapid expansion of synthetic data can be understood as part of this adaptive behavior as a strategy to innovate around regulatory limits. The challenge is ensuring that this evolution aligns with the ethical imperatives of medicine and public trust rather than diverging toward unregulated exploitation.</p><h3>Case Example: Synthetic Data for Predictive Care</h3><p>At Duke Health, researchers have used synthetic patient datasets to train predictive algorithms for sepsis detection. Because the data is simulated, these models can be tested and shared across departments without breaching HIPAA compliance. The result is faster development of life-saving tools and safer data collaboration. Yet the same methods could, in less regulated environments, be redirected to build predictive models of patient “value,” revealing how the same innovation can serve either public good or private gain depending on governance.</p><h3>Lessons for Industry</h3><p>For healthcare organizations, startups, and data vendors, the lesson is clear: synthetic data is neither inherently safe nor inherently dangerous. Its value depends on how responsibly it is generated, applied, and overseen. The goal should not simply be compliance, but the cultivation of ethical resilience because the capacity to innovate while preserving fairness, privacy, and trust.</p><h3>Actionable Checklist for Responsible Synthetic Data Use</h3><ol><li><p>Define ethical guardrails early: Establish clear boundaries on acceptable use cases. </p></li><li><p>Audit for bias: Validate that generated data reflects the diversity of real patient populations. </p></li><li><p>Ensure transparency: Document methods of data generation and the purposes they serve. </p></li><li><p>Govern collaboratively: Include legal, clinical, and technical perspectives in oversight. </p></li><li><p>Evaluate vendors rigorously: Choose partners who demonstrate accountability and compliance. </p></li></ol><h2>Conclusion</h2><p>Synthetic data represents one of the most promising tools for data-driven medicine, enabling innovation without directly compromising patient privacy. Yet it also reflects a broader evolutionary dynamic in which corporate and technological imperatives coevolve. The future of synthetic data will depend on our collective ability to channel that evolution toward ethical innovation rather than unchecked expansion. If guided by principles of fairness, transparency, and patient-centered care, synthetic data can serve as a catalyst for a smarter, more equitable healthcare system.</p>

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+ <p><strong>This is Space Cadet</strong>, a newsletter about Exploring the Horizons of Space and Faith.</p><p class="button-wrapper" data-attrs="{"url":"https://dominictanzillo.substack.com/subscribe?","text":"Subscribe now","action":null,"class":null}" data-component-name="ButtonCreateButton"><a class="button primary" href="https://dominictanzillo.substack.com/subscribe?"><span>Subscribe now</span></a></p>

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+import os
+import re
+import pickle
+import faiss
+from bs4 import BeautifulSoup
+from sentence_transformers import SentenceTransformer
+ROOT = os.path.dirname(os.path.dirname(os.path.abspath(__file__)))
+POST_DIR = os.path.join(ROOT, "posts")
+INDEX_PATH = os.path.join(ROOT, "faiss_index.bin")
+META_PATH = os.path.join(ROOT, "faiss_meta.pkl")
+def split_into_chunks(text, chunk_size=4):
+    sentences = re.split(r'(?<=[.!?])\s+', text)
+    chunks = []
+    for i in range(0, len(sentences), chunk_size):
+        chunk = " ".join(sentences[i:i + chunk_size]).strip()
+        if chunk:
+            chunks.append(chunk)
+    return chunks
+def load_html_posts(folder):
+    texts = []
+    ids = []
+    meta = []
+    for filename in os.listdir(folder):
+        if not filename.endswith(".html"):
+            continue
+        path = os.path.join(folder, filename)
+        with open(path, "r", encoding="utf-8") as f:
+            raw_html = f.read()
+        soup = BeautifulSoup(raw_html, "html.parser")
+        cleaned = soup.get_text(separator="\n")
+        chunks = split_into_chunks(cleaned, chunk_size=4)
+        for i, chunk in enumerate(chunks):
+            texts.append(chunk)
+            ids.append(f"{filename}_{i}")
+            meta.append({"source": filename, "chunk": i})
+    return texts, ids, meta
+def main():
+    print("Loading posts...")
+    texts, ids, meta = load_html_posts(POST_DIR)
+    if not texts:
+        print("No data found.")
+        return
+    print(f"Loaded {len(texts)} chunks. Embedding now...")
+    model = SentenceTransformer("sentence-transformers/all-MiniLM-L6-v2")
+    embeddings = model.encode(texts)
+    dim = embeddings.shape[1]
+    index = faiss.IndexFlatL2(dim)
+    index.add(embeddings.astype("float32"))
+    print("Saving FAISS index and metadata...")
+    faiss.write_index(index, INDEX_PATH)
+    with open(META_PATH, "wb") as f:
+        pickle.dump((texts, ids, meta), f)
+    print("Done.")
+if __name__ == "__main__":
+    main()