For nine months, I did not stand on a scale. I did not look at myself in a full-length mirror. I told myself I was busy. The truth was that I was frightened of what I might see.
I had reached my target weight, and my BMI had fallen below the range my prescriber and I intended. We discussed reducing my dose. Clinically, it was reasonable. Psychologically, it felt like a …
When the food noise stops, the identity crisis begins
“Is there a doctor or medical professional on board?” Answer that call and you may be treating anaphylaxis in a cramped cabin, mid-turbulence, with no medical history, no weight, no records, and no emergency department nearby. You should be able to assume one thing: that the aircraft’s medical kit holds the right medication, in a usable form, at the right dose. Under a new Federal Aviation Administration (FAA) proposal, that …
Epinephrine on airplanes should not depend on the airline
Artificial intelligence (AI) has rapidly reshaped cardiovascular imaging, particularly echocardiography, where machine learning algorithms now assist in image acquisition, chamber quantification, valvular assessment, strain analysis, and diagnostic interpretation. While these technologies promise enhanced efficiency and diagnostic accuracy, they also introduce an unresolved legal dilemma: When AI contributes to a missed diagnosis, who bears responsibility? Traditional malpractice principles designate the interpreting cardiologist as the primary legal decision-maker. Yet these doctrines evolved …
When AI misses a diagnosis, the cardiologist signs alone
I vividly recall the expression on Tim’s face during his initial visit to my exam room. Rather than relief, he exhibited suspicion. After enduring years of chronic pain, Tim had been referred to me, an interventional physiatrist, and had come to perceive a referral to “pain management” not as an opportunity for assistance, but as a judgment. He feared I would regard him not as a patient in need, but …
Why a pain management referral feels like an accusation
Last summer I received a $9,000 bill for an overnight hospital stay that I probably could have done without, medically speaking. It started two days earlier, when I went in for a prostate biopsy. Mind you, this was my third biopsy and each one, including this one, turned out to be negative. Nevertheless, my doctor keeps asking me to undergo these invasive …
Not medically necessary: the three words that cost me $9,000
For decades, stroke survivors have been told the same thing: Whatever function you haven’t recovered in six months, you likely never will. That assumption is now being dismantled. The American Stroke Association estimates that 1 in 4 American adults will experience stroke in their lifetime, often with devastating consequences. The 2011-2018 National Health and Nutrition Examination Survey estimated approximately 5.7 million U.S. adults living with at least one disability …
Is chronic stroke recovery really capped at 6 months?
They met in the U.S. Army and fell in love instantly. Though they went their separate paths, they both had brief but failed marriages and then reunited. It was a second marriage for both of them as they muddled through their previous baggage from their first marriages.
He was a captain in the Army, 6 feet tall. She was a 5’2″ petite, bright, and smart medic. They clicked quickly and reconnected. …
Alzheimer’s paranoia and the gun nobody locked up
I’d really like to talk with my fellow women.
There is a courtroom in Plymouth, Massachusetts where a jury is deciding whether a mother is criminally responsible for the deaths of her three children. This mother was a labor and delivery nurse. She had a five-year-old, a three-year-old, and an eight-month-old. Her defense says she was in the grip of postpartum psychosis. The prosecution says she knew exactly what she …
Maternal mental health and the myth of endurance
“Doc, your next patient is nonbinary.” I say some version of this to physicians when I teach about LGBTQ+ affirming care, then ask, “What is the first thought that comes to mind?” The responses come quickly: “I freeze.” “Oh, God. We were never taught that.” “I don’t know what to say.” “I don’t want to say the wrong thing.” Sometimes there is nervous laughter. Sometimes there is silence.
These are highly …
Why do physicians freeze with LGBTQ+ patients?
The Lindsay Clancy trial has raised a popular concern surrounding the notion of mothers having “intrusive thoughts” after delivery, specifically dangerous ones that, as in this case, may even be related to the murders of Lindsay Clancy’s three young children. However, “intrusive thoughts” are common after delivery and show up in many different ways in psychiatry, most of which are not dangerous. For example, one common and very scary …
Lindsay Clancy trial: intrusive thoughts versus psychosis
The most profound lessons in compassion did not come from textbooks or training. They came from the patients who invited me into their stories.
“Will you stay for a little while?”
A patient asked me this question after receiving news that would change the course of her life. I had no medical solution to offer. I could not take away her fear or change her diagnosis. All I could do was pull …
The true meaning of compassion in health care
I’d asked whether she was eating a lot of salt. Third admission in a year, I was going down her med list, and the question wasn’t on the list. It came out sideways, the way things do at the end of a long afternoon.
Same as regular. Like everyone.
Two grams a day is what I’d told her. First visit, second visit, printed on both after-visit summaries. She nodded each time. I …
Food is medicine programs need infrastructure to work
An excerpt from Off the Top of My Head: Stories from the Operating Room That Will Make You Laugh (or Cry).
“She has a size six head and a size four brain,” said my chief resident, Robert. “It saved her life.”
I was a junior resident at Shock Trauma and had called Robert in to see an 80ish-year-old patient named Hilda who had a large traumatic brain hemorrhage after a car …
Why a shrinking brain survived a deadly brain bleed
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I fitted a 20-year-old for a full set of dentures last year.
Not implants. Not a partial. A complete set, top and bottom, the kind I was trained to expect on patients in their seventies. By the time he sat in my chair, there was nothing left to save. Years of untreated decay had worked through enamel, then dentin, then the roots themselves, one tooth at a time, until removal was …
Why a 20-year-old needed a full set of dentures
After years of working with numerous health systems and my own experiences as a patient and caregiver, I have come to realize how challenging it can be to manage one’s own care. Care doesn’t stop when patients leave a health care facility. It is often just the beginning of a long journey for them. Most often, after a doctor visit or surgical procedure, a patient has an extensive to-do list: …
Care orchestration should start in the patient portal
On August 3, a nineteen-year-old sailor went overboard from the aircraft carrier USS Abraham Lincoln. Rescuers pulled him from the water and took him for medical care. According to his wife, he was attempting to die by suicide. The Navy has not confirmed this, but news reports say charging documents accuse him of malingering under Article 83 of the Uniform Code of Military Justice and being absent without leave under …
Punishing a suicide attempt teaches people to hide it
Somewhere tonight, a parent is managing a feeding tube and watching a monitor, deciding whether a small change in their child’s breathing is the start of something serious. Families of children with special health care needs do this around the clock. They run what amounts to an intensive care unit at home, handling medications and equipment that would test a trained nurse. They do it because they want their child …
Family-centered care starts with the parent at 2 a.m.
Most people have heard of cancer immunotherapy by now. These treatments help a patient’s own immune system recognize and attack cancer. The best-known examples are immune checkpoint inhibitors such as pembrolizumab (Keytruda) and nivolumab (Opdivo). These drugs release certain “brakes” that normally keep the immune system from becoming overactive. Another approach, called CAR-T therapy, is more involved. Doctors remove some of a patient’s T cells, a type of white blood …
Regulatory T cell reprogramming heads to trial in 2026
A recent article discussed the inequitable nature of infertility treatment, with which I agree. Yet, its remediation raised several ethical questions. First, why use IVF when there are 329,000 children in domestic foster care in 2024, many awaiting adoption? The drive to reproduce may be biological, but the desire for an infant is societal, and there is no evidence that adopting an older child is less rewarding.
Foster children are in …
The ethical concerns with IVF we are not discussing
There is a question I have learned to ask that almost never appears in any clinical protocol. Not “Where does it hurt?” or “How long have you had this problem?” But something much quieter: “Is there anything else you’d like me to know?”
The answers to that question have taught me more about patient care than I expected. Over time, I’ve realized that patients rarely come into the clinic carrying only …
What patients don’t say in the dental chair
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