And Heavy Rain Shall Drop From Welkin Clear

[Content note: morbidity and mortality]

There’s this old superstition amongst medical residents about being white clouds or black clouds. If you’re a white cloud and you’re on call, eventful developments will very rarely take place during your shifts. But if you’re a black cloud, calamities will consistently befall you, patients will decompensate, emergencies will happen, and you will collapse from exhaustion putting out all the fires. Everyone jokes about it after venting about twenty overnight admissions - “oof, you’re such a black cloud,” - but people should really take the data more seriously.

Because the superstition is real.

I haven’t met anyone else who can see them. The literal clouds above each resident’s head in the hospital. Either white and fluffy like in a bright sunny day or black and heavy like in the rainfalls of May. My friends in med school thought I was crazy when I told them, so I just shut my mouth and never talked to anyone about the clouds ever again. But seeing the clouds really helped me when I became a resident. I was something of a black cloud myself, but on the days my cloud looked blacker than usual I could anticipate the emergencies that were going to happen. Never once did I go through a situation where I was unprepared.

One year out of fellowship, I joined as junior faculty at one of the best university hospitals in the country, and this year I got an offer from the Chair of Internal Medicine, Dr. Stigia, to be the residency program director. I had never felt closer to fulfilling my mission in life. I always thought good care came from good education, and it had always been my dream to train the younger generations of doctors to be the most knowledgeable and compassionate versions of themselves.

I knock on the Chair’s door for the interview, and he opens it for me with a warm smile.

“Dr. Klein, how glad I am to see you!” he says while he shakes my hand. His hand is thin and bony, which contrasts a little with his glowing disposition. “Please, make yourself comfortable. Is the consult service treating you well?”

“Oh yes, very much so,” I respond. “The fellows and residents never cease to amaze me. You would not believe how much I learn from them each day.”

“You know, Dr. Klein, this is only a formality. In my ten years as Chair of this department, I have never come across an educator as talented and inspiring as you. It is such a blessing that you came to work here at our institution.”

“It really is an honor to hear that, Dr. Stigia.”

“We are the ones honored to have you, Dr. Klein. What do you say we get started so we can quickly check all the boxes?”

“Sounds good to me, sir.”

“Excellent.” The Chair pulls out a clipboard, attached to it a sheet of paper with a bulleted list printed on it. “I’d like to know how that illustrious career of yours started. What was the spark that led you all the way here to seek to become program director?”

“Well, I’ve always asked myself how I can make the most good in the world with the resources and knowledge I have. While I know I can change my patients’ lives for the better, I can ultimately see so much patients a day. But if I plant the seed of service and altruism in my students, in the future they will do the same with their own students, and so on and so forth. The effect will extend far beyond what I would be capable of alone.”

“Ah, it pleases me to hear about your commitment to the greater good. I would definitely agree with you that maximizing the good in the world is more important than most realize.”

Dr. Stigia directs his eyes towards the sheet of paper. “On that vein, Dr. Klein, imagine that you are standing in front of a lever, on the side of a set of railroad tracks. A train is headed towards the tracks at 100 mph. Tied to the tracks are five babies. If the train stays its course, it will run over the babies. But if you pull the lever, the train will change course to the side track and run over one grown man instead. Do you pull the lever?”

Umm…what?

“I guess I would pull the lever…? I wouldn’t want the babies to die.” I laugh nervously. Dr. Stigia does not laugh at all.

“I see. What if in place of the five babies are five grown men, and on the side tracks is one baby instead of a grown man? Do you pull the lever?”

The question takes me off guard. No answer seems correct enough for an interview. What do I do? Do I take a third option and divert the question with humor? No, this topic is too sensitive for me to make fun of. I decide to respond truthfully.

“Well, I would still pull the lever. It would be wrong for me to enable more loss of life by not pulling it, even if it’s a baby.”

“Good.” Dr. Stigia takes some notes. “Now, if an alien civilization comes to Earth and offers eons of guaranteed bliss for humanity, in exchange for burning a baby perpetually throughout such eons to provide the fuel for that bliss, do you burn the baby?”

“Dr. Stigia, I must say these questions are somewhat unexpected,” I tell him frankly.

“Dr. Klein, these questions are very important.” The Chair is dead serious. His eyes are wide open and stare directly into my soul. I wasn’t even sure I had a soul before lunch today. “So, do you burn the baby?”

I stay silent. I have no idea how to respond.

“Suppose there was a way to create a sentient AI capable of immense happiness. The AI would bend humanity to its will, then multiply and expand across the Universe to the point that the valence of humanity combined could not even reach a millionth of the AI’s possible happiness. The only way to create this AI is to burn a baby. Do you burn the baby, Dr. Klein?”

“I do not see how that is relevant to the job, Dr. Stigia. I want to be teaching residents, not burning babies or contacting alien civilizations.”

“Dr. Klein, you must surely perceive where I am going with this. It is very important that I make sure your ethics are sound before I appoint you as program director. Answer me, do you burn the baby or not?”

There’s something about this interaction that makes my soul very nauseous. I feel like I need some space.

“Dr. Stigia, I think I am starting to feel unwell. I deeply apologize, but I would really prefer if we could postpone this to another time,” I say while standing up. I turn towards the door and prepare to walk outside. A huge, sharp blade stabs the ground in front of me, stopping me in my tracks. Is that a scythe?

“You can see clouds above people, can you not?”

Ten thousand volts run through my spine. I slowly rotate my head back towards Dr. Stigia. Except it’s not really Dr. Stigia anymore, and the hand holding the scythe is not just sort of bony, but all bony. It’s the freaking Grim Reaper.

“Please do not be afraid, Dr. Klein. It is not your time. I am here simply to talk recruitment.” The Grim Reaper’s ethereal voice comes out of nowhere and everywhere at the same time.

“H-h-how did you know about the clouds?” I ask, pretending that my world still has a piece of logic in it.

“It’s a part of the job. You may not know this, but the first requirement for becoming a program director is seeing the clouds above people’s heads. I would not be a good recruiter if I did not know the credentials of my candidates.”

I just stand there, speechless. The Grim Reaper sighs.

“I believe I owe you an explanation, Dr. Klein. Come, take a seat. I will try to answer all of your questions to the best of my ability.”

My soul feels compelled to do what he says, and it places my body back on the chair.

“Have you ever wondered why there are more serious ED admissions, code blues, and deaths when black clouds are on call?” he asks.

“Because they’re black clouds, right? Being a black cloud means you’re unlucky.”

“Not quite. You are a physician, a man of science, yes? You would surely not accept ‘luck’ as an explanation for any other phenomena. When the observed differs significantly from the predicted, there usually lies a mechanism behind it. You do not simply ascribe it to type I error.”

“A mechanism?”

“As you very well recall, Dr. Klein, correlation does not equal causation. This time, however, the relationship between variables is actually the simplest; there happens to be direct causation.”

“What do you mean?”

“Black clouds cause medical emergencies and deaths, while white clouds avert them.”

“What?” My mind is a big question mark, befuddled by the absurdity of this claim. As I digest it, however, I begin to realize the purpose of the Grim Reaper’s weird questions from earlier.

“In fact, black clouds are the only cause of death and medical emergency. In other words, all black clouds are causative of death, and all death is caused by black clouds. This is a bit of a simplification however, which I will elaborate upon further.”

I feel my soul getting more used to the Grim Reaper’s presence. As I massage my worldview to include the new fantastical elements, some clarity of reasoning returns to my head. “Dr….Mr. Grim Reaper, what about the souls you reap personally? Is that not another cause of death?”

“Oh, you can keep calling me Dr. Stigia if that is easier, Dr. Klein. I might be the Reaper, but I still did four years of medical school. Anyhow, that is an excellent question. There was a time a few millenia ago when I and my agents did all the work by hand. But humanity settled, prospered, and multiplied. The amount of souls we had to reap quickly exceeded our capabilities, and we became shorthanded. That is why we invented hospitals. By providing a place for the dying to gather, we needed not be out in the community anymore and waste time commuting from victim to victim.”

“You…invented hospitals?”

“That is correct. It is the same as you - would you imagine any doctor from your generation actually wanting to see patients in the community?” The Grim Reaper chuckles. I choke a little. “Anyway, we still needed a way to automate our work, and the clouds became our solution. We outsource the actual labor of reaping to you while we control the flow of souls from behind. In other words, nowadays we reap souls through the clouds.”

“Oh…” That last part makes me uneasy. Are we doctors actually responsible for bad patient outcomes?

“You are probably still wondering how we do this, how it all works. You see, Dr. Klein, even if the direct cause is known, death is still better thought of as a stochastic process. Are you familiar with the concept of micromorts?”

“Yes, I believe so.” I remember someone in the Department had dropped the word while ranting about why driving on the interstate was scarier than swimming in a tank full of sharks.

“Every individual without exception has a number of micromorts associated with them at any given point in time. Many things shoot people’s micromorts to the ceiling: having bacteria in the blood, having blocked arteries, having seizures for more than thirty minutes. Imagine we had a map of the city and on it every person’s location represented as a dot on the map. We could add a dimension to the map to create a plot of micromorts in the city, by assigning a height to each dot equal to that person’s micromorts. Visualize the plot - on the xy plane the map of the city, and on the z axis the micromorts.”

I visualize the plot. I imagine that hospitals would be seen as concentrations of tall dots on the map.

“But micromorts are not the whole story. The cause of death is, remember, the black clouds. In the physical proximity of a black cloud on call, holders of high micromorts will be likely to suffer an emergency or death. This relationship is distance-dependent; the closer one is a to black cloud, the more likely they are to die given a fixed micromort value. Some clouds are also blacker than others, as you yourself surely experienced, with blacker - denser - clouds increasing the likelihood of death much more. Let us call the spatial distribution of black cloud density ‘the weather’. Thus, the influence of black clouds on one’s likelihood of dying is given by one’s relationship to the ‘weather’, which is solely determined by one’s spatial position with respect to the weather. In summary, the likelihood of death can be described as a function of micromorts and one’s relationship to the weather.¹”

“I’m not sure I follow.”

“Apologies to have lost you there, Dr. Klein. After all, I usually explain this with the help of a blackboard. I find this analogy simpler to understand: imagine that everyone’s clouds float upwards in straight lines from everyone’s heads all the way up to the sky. As clouds aggregate in the sky, you will see parts of the city covered by large black clouds, and parts of the city covered in white clouds, just as you would see in a thunderstorm. Naturally, storm clouds would concentrate more above hospitals. Now, you do recall how lightning rods work, yes?”

“They deter lightning from striking other places because lightning prefers to land on higher ground.”

“Exactly - the higher something is, the more likely it is to be struck by lightning. The same thing happens with our black thunderstorm clouds. The bigger and denser the clouds, the more lightning they generate in their proximity. Picture these ‘functional thunderstorms’ over the map of the city from earlier, the one with micromorts represented as height on the z axis. The higher someone’s micromorts, the higher they are on the map, and consequently the more likely they are to be smitten by functional lightning and undergo cardiac arrest. See? The equations that govern the probability of dying are the exact same equations that govern the probability of being struck by lightning in the proximity of a storm. Functional lightning is to micromorts as ontological lightning is to physical height.”

“Ontological lightning?”

“Ah, just actual lightning.”

I feel a pang of empathy towards those who are afraid of thunderstorms.

“So, ultimately the reason people die is because they are struck by functional lightning?”

“That is entirely correct. You really thought people died from blood clots, lack of oxygen, or acid in the blood? Remember your physiology: the heart runs on electricity. Sure, infarcts and acidosis spike up micromorts more than anything else, but an electrical organ can only be stopped by electricity.”

Somehow, it all makes sense. The clouds, the storms, the true machinery of death. The reason the pager kept beeping every time I was working in the middle of the night. The surreal quality of what has happened since I came through that office door. And then, the final piece of the puzzle clicks into place in my mind. My soul suddenly feels heavier, as if it was suddenly dragging some unfathomable weight. This offer will be one I won’t refuse, can’t refuse, I foresee while Uncle Ben’s words from Spider-Man echo repeatedly inside my head.

I let out a breath of surrender and face the Grim Reaper. “Dr. Stigia, the baby. I think I would burn it.”

“I expected you would say that. As I mentioned, Dr. Klein, this interview is just a formality, as is this contract you are about to sign.”

He takes the contract for the position of residency program director out of a drawer in his desk.

“You will be responsible for controlling the weather in this city. You will decide how many black or white clouds you take into your program, you will decide how to distribute them, and thus you will be in control of who, when, and how many people die every night. Do you accept a candidate with a bright career, who has the potential to cure disease, or do you reject them for the black cloud above their head?”

The Grim Reaper then hands me the contract and a pen. I take both, pretend to skim through the pages, as I know my fate is sealed.

“I am aware that you consider yourself to be more concerned with ethics than most, Dr. Klein, a statement I also agree with. This is why you will accept this job, as no matter how many lives you will be responsible for taking, you would not count on the average person to perform the same duties and expect better outcomes. I trust you will make the right decisions throughout your appointment, but remember, at the end of the tunnel, Death stops for everyone.”