I’ve been thinking a lot about what we are losing in modern medicine. We were taught to treat the patient, not just the labs. To listen. To notice patterns. To pay attention when something doesn’t quite fit. To ask, “What am I missing?”
Angus Fletcher, a professor of story science at Ohio State’s Project Narrative, calls this primal intelligence. He names four capacities: intuition, imagination, emotion, and common sense.
In medicine, we talk about some of these under other names. We call emotion bedside manner. We fold common sense into clinical decision-making. We prize pattern recognition, which really lives inside intuition, and we train it hard.
Imagination may be the one we’ve lost. Its clinical name is curiosity, and it is the first thing to go when we are rushed and burned out, because it is the one that requires the most slack.
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You can be kind in a visit that is already running behind. You can apply judgment. You cannot wonder.
And pattern recognition on its own is only as good as the pattern we were handed. I was taught that Sjögren’s disease is dry eyes and dry mouth in a woman in her fifties with poor dentition. It is a systemic autoimmune disease that can announce itself years earlier as fatigue, neuropathy, and dysautonomia, potentially long before anything feels dry.
A clinician can recognize the taught pattern faithfully and still miss the patient in front of them. Worse, they will miss her confidently, because she does not match the pattern they were taught to trust.
That is where imagination earns its keep. Pattern recognition tells you what you have seen before. Curiosity is what makes you ask about what you haven’t or what doesn’t make sense. Not instead of evidence-based medicine. Alongside it.
Somewhere along the way, we optimized medicine around algorithms, protocols, productivity metrics, and checkboxes, and in the process we squeezed out some of the very human skills that make a great clinician great. There is another consequence of this that we don’t talk about enough.
Patients with complex, chronic, multisystem illnesses like mast cell activation syndrome (MCAS), dysautonomia, and Sjögren’s disease are increasingly broken down into smaller and smaller pieces. The joints go to one specialist, or several. The hormones go to another. The heart rate and autonomic symptoms go somewhere else. The GI symptoms get their own specialist. The pain gets another.
Each clinician may be looking through an increasingly powerful microscope. But who is looking through the telescope? Who is stepping back and asking: How does all of this fit together? What is the pattern? What are we missing because we divided the patient into organ systems?
Part of the problem is economic. We have built a health care system that is very good at compensating for doing things like procedures, tests, visits, interventions and remarkably bad at compensating for thinking.
The cognitive work of caring for a complex patient is enormous. Synthesizing the history. Connecting the dots. Recognizing patterns and exceptions to the pattern. Holding multiple possibilities at once. Knowing when the story doesn’t fit the algorithm. Seeing the human being underneath all of it.
That work takes time. It takes experience. It takes attention. And we do not value or reimburse it anywhere near what it is worth.
And when no one is holding the whole picture, the patient becomes the only person left to connect the dots.
I am part of this tension, too. Over three years, as my practice shifted toward caring for this population, I took a pay cut of more than 30 percent. I made that shift in part because I am one of these patients. I live with Sjögren’s disease and dysautonomia.
And I was burning out anyway. I was drowning in the inbox, in what I came to think of as my MyChart love letters. I was trying to take a complete history, manage complex medical trauma, and build enough trust to be useful, all inside a new-patient slot that was never long enough for any one of those three things.
Meanwhile, I had three young children, a marriage I wanted to keep, and my own participation in a clinical trial, as a patient. In 2025, I left academic medicine and opted out of the insurance-based system because I could no longer practice the way I believed medicine should be practiced inside its constraints. Now I practice mostly virtually, in a direct-care model, where I can take the time a complicated history actually requires.
I am not going to pretend that solves the problem. It solved it for me, and for the patients who can reach me and afford me. We can build beautifully designed, highly specialized microscopes, charge a premium for each one, and still leave the patient without anyone responsible for seeing the whole picture.
The answer isn’t less specialization. It isn’t less science. It isn’t less technology. It is both/and. We need clinicians who are exceptionally skilled at looking through the microscope, and we need clinicians who can step back and see through the telescope.
We need to help clinicians learn or re-learn to use their primal intelligence. And we need to build a system that gives them the time, space, permission, and compensation to actually use it. Because telling clinicians to listen to the patient isn’t enough if we’ve built a system that makes truly listening nearly impossible.
So I’ll ask the question I keep coming back to: In your practice, or in your care, who holds the telescope? Not who should. Who actually does?
If you’re the clinician and the answer is you, I’d like to know what it costs you: the unbilled hours, the notes finished at 10 p.m., the visits that run long because the story finally started making sense at minute 22. And I’d like us to be honest that we have quietly assigned this job to primary care, which is drowning. Twelve minutes and a full panel is not a telescope. It’s a keyhole.
If you’re the patient and the answer is you, you already know it. You’re the one carrying the binder, repeating the history for the ninth time, noticing that the medication started three weeks before the symptom did, translating between six specialists who have never spoken to one another. You have become the only person in the room holding the whole picture, and you are doing it while sick.
That is the part I don’t think we have reckoned with. We didn’t eliminate the telescope. We handed it to the person with the least support and the most at stake.
So tell me: Who is holding it where you sit? I want to hear from both sides of that visit. I suspect the answers overlap more than either of us expects.
Kara Wada is a quadruple board-certified pediatric and adult allergy and immunology, lifestyle, and functional medicine physician, a Sjögren’s disease specialist, and a Sjögren’s patient herself. She spent nine years on faculty at The Ohio State University Wexner Medical Center, where she served as associate program director of the allergy and immunology fellowship and led the Mast Cell Center of Excellence.
In 2025, she left academic medicine to build the kind of practice she could not find as a patient: the Immune Confident Institute, a national direct-care immunology practice licensed in 27 states. She treats the patients the health care system sends ping-ponging between specialists, people with complex, chronic, multisystem disease including mast cell activation syndrome (MCAS), dysautonomia, Sjögren’s disease, immune dysfunction, and the seronegative and “in-between” diagnoses that do not fit neatly into a single specialty.
Her premise is simple: These patients are not the problem. Fragmented care is. Medicine has become exceptionally good at looking through microscopes while losing sight of the telescope, the bigger picture of the person in front of us. Her work challenges a health care culture that demands compliance when it should assume competence, and aims to make strategic, compassionate immune-directed care the standard, and the exam room a place where patients are finally seen, heard, and believed.
Most of her reach is built outside the exam room. Her YouTube channel drew roughly two million views this past year, and more than 100,000 people follow her work across platforms, including a Sjögren’s community of about 6,600. She founded and hosts the Virtual Sjögren’s Summit, now in its sixth year and drawing some 4,300 registrants worldwide. She appears regularly on national television and in the health press, including Prevention, SELF, Good Housekeeping, WebMD, Medscape, and MedPage Today, and she writes for KevinMD on the diagnoses that live in the shadows and the medical gaslighting that surrounds them.
A TEDx speaker and sought-after keynote, Wada speaks to clinician and patient audiences about complex immune disease, the experience of being disbelieved, and what changes when the physician is also the patient. She is also an unlikely pageant titleholder, having served as Dr. Ohio America 2022 and Dr. Midwest America 2023, and has written about how pageantry sharpened skills medicine rewards but rarely teaches.
She earned her medical degree with honors from the University of Illinois College of Medicine at Peoria and completed internal medicine-pediatrics residency, allergy and immunology fellowship, and clinician educator fellowship at The Ohio State University and Nationwide Children’s Hospital. She lives in Columbus, Ohio, with her medical school sweetheart turned husband, Akira, and their three children.
