A patient sends a portal message at 9:17 p.m. on a Tuesday. “Hey, I’ve been having some chest tightness when I climb stairs. It comes and goes. Also can you refill my metformin and check if my last A1C was OK? I don’t want to come in if I don’t have to.” This message requires clinical triage. It requires chart review. It requires a decision about whether to initiate a …
How patient portal message volume drives physician burnout
Cortisol. Almost always cortisol. I say this to patients more than almost anything else. And I say it having lived it myself, years of high-output clinical work, late nights, early mornings, and the particular exhaustion of lying in bed completely depleted but unable to actually fall asleep. Tired but wired. It is a real physiological state, and it has a name: hypothalamic-pituitary-adrenal (HPA) axis dysregulation. It is not insomnia in …
Is HPA axis dysregulation causing your chronic insomnia?
I have treated over 10,000 bariatric patients across my career, and if there is one issue that comes up more than almost anything else, it is protein. Specifically, patients not getting enough of it. The research confirms what I see every day in practice. Only a minority of bariatric patients reach the recommended minimum of 60 grams per day, resulting in the loss of fat-free mass rather than the …
The hidden risk of protein deficiency in bariatric surgery
Knee osteoarthritis (OA) remains a leading cause of chronic pain and reduced mobility, affecting millions of adults worldwide, particularly those over age 50. As cartilage deteriorates and inflammation increases, patients often face pain, stiffness, swelling, and limitations in daily activities. Although no cure exists, a structured, escalating treatment plan can significantly alleviate symptoms, preserve function, delay disease progression, and help many individuals avoid or postpone surgery. Current guidelines from the …
Knee osteoarthritis demands layered pain management
One of the most common questions I hear in rehabilitation is not asked during therapy sessions. It is usually asked quietly by a family member after the session ends. “Will my mother walk again?” Families rarely ask about therapy intensity or functional scoring systems. They do not ask how many minutes of treatment occurred that day. They ask about walking. Walking represents independence. It represents the possibility of returning home. …
Why walking matters most in post-acute rehabilitation
In modern times, we frequently encounter messes in our public life. This seems particularly true in American health care, and it is certainly true in our politics. But few citizens seem to put the two issues together sufficiently to effectively demand change. Putting them together is what this article is about.
According to the nonprofit public interest group Open Secrets, individuals and political action committees spent a record $4.5 billion in …
Health care lobbying is destroying the U.S. system
A patient in his 20s recently came to see me in a state of severe distress. He described feeling consumed by his thoughts, constantly anxious, unable to function, and deeply exhausted. His sleep had collapsed. His sense of identity felt lost. He was experiencing persistent passive suicidal thoughts, not because he wanted to die, but because everything felt overwhelming and unrelenting.
Within three days of starting low-dose lithium at 150 milligrams …
Low-dose lithium treats suicidal ideation safely
The treatment of cardiovascular diseases has advanced at an extraordinary pace over the past half-century resulting in an age-adjusted 60 percent reduction in heart disease death rates. This dramatic decline is directly attributable to primary and secondary preventive therapies such as statins and small interfering messenger RNAs along with disruptive technologic advances in procedural techniques. New pharmacologic options for thromboprophylaxis and novel therapies for heart failure …
Why cardiovascular medicine should focus on patients, not environmental advocacy
Every week in the pediatric emergency department, I see the consequences of adolescent substance use that started too early and went unaddressed for too long. A teenager in crisis. A family blindsided. A window of prevention that closed long before anyone realized it was open.
We keep asking the same question: How do we reach kids before it gets to this point?
The answer, it turns out, might already be sitting in …
Peer-led storytelling in adolescent substance use prevention
The modern acquired immunodeficiency syndrome (AIDS) epidemic was first recognized in the United States in early June 1981, when clusters of rare opportunistic infections were reported in young gay men in Los Angeles and other cities. Before the cause was understood, it was commonly called “GRID” (gay-related immune deficiency). In popular and some medical discussions, it was also referred to as the “gay plague,” “gay cancer,” and similar gay-specific labels. …
The hidden realities of the HIV/AIDS epidemic and U.S. health care policy
For years, I have heard breast cancer survivors share a common refrain: “I expected to lose my breasts. I did not expect to lose the ability to feel.”
Yet in exam rooms across the country, persistent numbness after mastectomy remains underdiscussed and poorly understood in routine care. It is often framed as an inevitable side effect rather than a life-altering outcome that impacts quality of life after cancer.
We have made tremendous …
Living with numbness after mastectomy: the unseen impact on survivorship
Most emergency departments feel perpetually behind. The waiting room fills, ambulances stack, and staff move quickly yet still feel behind. The reflex explanation everyone gives is capacity. We need more beds, more rooms, more space. That explanation is intuitive. It is also often incomplete.
In many departments, nothing meaningful happens after triage until a patient is placed in a permanent treatment room. No bed means no provider evaluation. No provider evaluation …
The physician-in-triage model and rapid evaluation in emergency medicine
I have treated over 10,000 bariatric patients across my career, and if there is one issue that comes up more than almost anything else, it is protein. Specifically, patients not getting enough of it. The research confirms what I see every day in practice. Only a minority of bariatric patients reach the recommended minimum of 60 grams per day, resulting in the loss of fat-free mass rather than the …
Why bariatric patients struggle with protein and how to fix it
You tell me it is all in my head.
As though my head were a small room where false alarms
ring for sport,
like I have no better way to spend my time and life.
You hold films up to the light,
of bones and blood,
nothing cracked or out of place,
or a catastrophe waiting in the wings
that has earned a name in your stack of books.
My blood you have drawn
has traveled through your machines
and has …
A patient’s poem on invisible illness and trauma-informed care
A dry cough can be one of the most misleading symptoms in medicine. At home, it can dominate the emotional climate of an entire household. It interrupts sleep, breaks conversations, unsettles meals, and keeps caregivers in a state of low-grade vigilance. It appears in cold air, at the beginning of a speech, during the first few sentences of a phone call, or in the quiet moment when everyone is finally …
How a minor dry cough amplifies caregiver burden in home health care
If you have nagging pain deep in your lower back or one buttock that never seems to settle, you are not alone. Many people chase answers through discs, nerves, or muscles, yet the real source turns out to be the sacroiliac (SI) joint. This connection between the base of your spine and your pelvis is built for stability with just a hint of motion. When it becomes irritated or unstable, …
How to treat sacroiliac joint pain effectively today
I want to tell you something attorneys already know but will never say to your face. When your expert report lands in their inbox and they read it, I mean really read it, they know within the first two paragraphs whether they are calling you again. Not after the case. Right then. And if the answer is no, they do not tell you. They do not give feedback. They do …
Why clinicians fail at writing expert reports
In September 2025, The Atlantic reported on a frenzy surrounding leucovorin, a folate derivative long used in oncology and rheumatology. Families desperate for answers were suddenly told it might be a miracle therapy for autism. Waitlists stretched years, clinics were overwhelmed, and hope surged. The problem was not just scientific, it was political. When President Trump and HHS Secretary Robert F. Kennedy Jr. endorsed leucovorin, they amplified demand …
Leucovorin for autism: Why physicians must protect hope from hype
In health care, we are trained to measure what we can quantify. We check blood pressure, glucose, cholesterol, and weight. We monitor lab trends and adjust medications. We look for numbers that confirm risk. What we do not routinely measure is whether a patient is living in a constant state of stress, even though the signs are often right in front of us.
In dentistry, those signs are hard to miss.
Over …
The hidden link between chronic stress and oral health
Modern medicine loves numbers. LDL. A1c. BMI. Tumor diameter. Pounds lost. They are easy to measure, easy to track, and easy to celebrate. But none of them are the disease itself.
As GLP-1 prescribing accelerates and insurers increasingly define success by weight reduction, we are repeating a familiar mistake: Elevating a surrogate marker to the status of a biological endpoint.
BMI was never designed to diagnose disease in individuals. Adolphe Quetelet created …
GLP-1 agonists and weight loss: Treating the disease, not the number
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