The referral came from a mental health clinic. A woman had been putting the hose of a handheld vacuum cleaner into her mouth, pushing the nozzle toward the back of her throat, and turning it on. She had done this more than once a day for several days. The clinician who examined her found bruising and abrasions throughout her mouth. She was referred to me because her mouth and throat …
Diagnostic overshadowing and the war in her throat
Every night on mainstream streaming platforms, I see the same rotation of charity commercials: protect dogs, save Syrian children, shelter American runaways, support childhood cancer care, preserve wildlife. Each one asks for a small monthly donation (99 cents, $5, $19), and each one insists that without your contribution, the suffering continues.
As a physician, I don’t respond to the emotional script. I respond to the ethical one. And the ethical script …
Why do charity commercials leave clinicians uneasy?
One day, my mother suddenly was unable to finish her sentences. She was admitted to the local hospital, where a CT and MRI revealed multiple lesions. Ultimately, she was diagnosed with a glioblastoma. The neurosurgeon told us she was too old to operate on and recommended hospice, adding that she was unlikely to live more than six months. At another hospital, she was offered radiation, chemotherapy, and infusions, as her …
The insurance maze that single-payer health care would end
Health care these days has encountered a genuine Catch-22 with a spiral downward effect: Declining real reimbursement rates push practices to increase patient volume to maintain revenue; higher volume compresses time for thorough documentation; and inadequate or incomplete documentation then triggers payer audits, denials, and clawbacks (recoupments) of already-paid claims, which feeds into declining reimbursement. Multiple sources discussed below, from Medicare data, physician surveys, CMS actuarial analyses, industry reports, …
Moral agency in medicine is being squeezed by payer audits
A patient recently told me she hadn’t seen a doctor in six years. Not because she felt perfectly healthy, but because nothing had ever felt “bad enough” to justify an appointment. By the time she came in, her blood pressure was stage 2 hypertension, her fasting glucose was in the prediabetic range, and she was carrying a level of chronic stress she’d simply learned to live with.
None of this is …
Why the importance of primary care is easy to miss
There was a time when becoming a physician meant entering a profession in which your experience was not merely appreciated; it was actively sought after. My father belongs to a generation that remembers this world. He once told me about the difficult decision he faced: whether to continue as chief of staff at a primary health care center or leave and establish his own practice. The difficulty was not finding …
Experienced physicians and patient safety defy spreadsheets
In the early 1990s, while the American Academy of Pediatrics (AAP) was formalizing its vision of the “medical home,” we were already living it, without a name. At Minot Air Force Base in North Dakota, our pediatric team operationalized what would later be codified: interdisciplinary care, family partnership, coordinated services, and continuity across settings. We didn’t call it a medical home. It was excellent pediatric care, and we simply made …
The history of the medical home includes an Air Force base
Every patient who has spent time in an emergency department knows it’s overcrowded. They’ve sat in the waiting room for hours. They’ve watched physicians move fast and nurses move faster. They’ve heard the department through the curtain: the monitor alarms, the overhead pages, the sound of a place where everyone is doing too many things at once.
What they haven’t seen is the board.
The board is how an emergency physician experiences …
Why I wrote an emergency medicine novel about 1 night
I currently split my time between two worlds. I see patients in clinic and also work on AI and innovation in the health system. Most days, the dichotomy is an asset. Some days, it feels like it is two different jobs that share one calendar.
AI has closed much of the knowledge gap in medicine and did it faster than expected. The chart review, the differential diagnoses, the literature search, it …
AI and clinical judgment: why patients still trust doctors
For those of us who have spent decades practicing medicine across multiple systems, the daily reality feels less like the noble healing art we trained for and more like a corporate assembly line. We watch as science-based, patient-centered care is nickel-and-dimed by administrators into mere metrics. In our exhaustion, we can easily identify with Odysseus. Like the legendary king wandering the dark seas, we feel a profound sense of alienation, …
Moral injury in medicine is an odyssey without Ithaca
It has already been said, “We will die in the system we create.” The statement raises a larger question: What do we mean by death? Death can be spiritual through excommunication, economic through expulsion from work, social through eviction from a community, psychological through exclusion and loss of sanity, or physical through extinction. Birth and death often result from forces beyond an individual’s control. Yet death can also become intentional. …
AI and assisted dying raise questions of accountability
There is a small, unreasonable part of us that expects our doctors to stay in one place forever.
We know better, of course. We know they grow older, become tired, change jobs, and make plans. Yet the person we bring our uncertainty to is not supposed to become another uncertainty. We may notice the gray hair without quite imagining the day when someone else opens the door.
Few relationships ask so much …
Losing your doctor: the grief no health system notices
Becoming a physician is one of the longest professional journeys in America. The path typically requires four years of college, four years of medical school, and three to seven or more years of residency and fellowship training. For surgeons, training routinely extends well beyond a decade after college.
The investment is financial, professional, and deeply personal. Medical graduates routinely carry substantial educational debt, spend thousands of hours studying, take licensing examinations, …
A national hotline could track bias in physician discipline
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Care does not have to be finished in one encounter. But it must not be allowed to disappear between encounters.
When primary care clinicians say they cannot adequately manage their patients’ concerns in 15 minutes, I take that seriously. A patient may arrive with a new symptom, several chronic conditions, medications prescribed by different clinicians, and questions about what has changed. The clinician faces that complexity alongside chart review, examination, documentation, …
The 15-minute appointment is not the boundary of care
One night, during cross coverage with residents, I was called to provide clinical oversight for a frail older woman admitted from the emergency department. She had multiple comorbidities and a deteriorating clinical picture, but she had been placed under observation status. I was perplexed.
When I asked residents why observation was so often selected, the answer was usually some version of this: “It is easier to change the patient to inpatient …
Observation status is a clinical choice, not a billing one
We spend our days in the quiet reality of clinical practice. We chase elusive diagnoses, weigh the fine distinctions of symptom presentation, and measure our clinical instincts against rigorous decades of peer-reviewed science. We sit across from human beings in moments of vulnerability, applying a lifetime of anatomy, neurobiology, and pharmacology to parse real suffering from pathology.
Yet, step outside the exam room door, and we are met with a deafening …
3 reforms to counter wellness influencers in practice
Patients considering cosmetic limb lengthening usually begin with one question: How much height can be gained? That question is understandable, but it should not drive the decision. The more important issue is who will remain responsible for the patient’s care throughout the process and what will happen if recovery requires extra attention.
Cosmetic limb lengthening is often presented as a procedure that increases height. Technically, that is the goal, but it …
Choosing a limb lengthening surgeon requires accountability
Physicians reassure people every day:
We usually say these things with good intentions. We want to reduce fear, provide perspective, and help patients leave our offices or emergency departments feeling safer than when they arrived. But sometimes reassurance does not reassure.
The patient continues asking questions. They return to the emergency …
How to reassure patients: 5 steps beyond normal tests
For years, I thought good doctors always said yes.
Can you squeeze in one more patient? Yes. Can you answer this message before you leave? Of course. Can you finish this chart tonight? Yes. Can you take care of just one more thing? Absolutely.
It rarely felt like a major decision. Each request seemed small. A few more minutes. One more patient. One more message. But small yeses have a way of …
Setting boundaries as a physician doesn’t mean caring less
Ask most physicians outside emergency medicine how they’d handle a patient presenting with three possible diagnoses, incomplete labs, and a deteriorating vital sign trend, and you’ll usually get a version of “I’d want more information first.” Ask an ER physician the same question, and you’ll get an action plan within seconds. That gap isn’t intelligence. It’s training. And I think it’s worth naming exactly what that training builds, because most …
How emergency medicine decision making works under pressure
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