It is time to dethrone the office visit as the king of primary care physician compensation and how the work of a primary care physician is defined.
Several months ago, a reporter asked me how many patients I see in a typical day. I told her that the question should not be how many patients I see each day, but how many patients I take care of each day, a number …
Primary care compensation models: Why wRVUs are obsolete
Physicians are often described as leaders of the health care team. The language shifts, quarterback, captain, final decision-maker, but the implication is constant: someone is clearly in charge. At the bedside, the reality feels more complicated.
In every functioning system, there is a final point of responsibility, the person who answers when outcomes are poor. In medicine, that person remains the physician. We sign the charts. We carry the malpractice risk. …
Why physicians are absorbing risk, not leading
In our modern professional landscape, we are witnessing a phenomenon I call the Schism of Time. It is not just a gap in age; it is a fundamental difference in how we perceive value, and “spend” the hours of our lives.
As technology accelerates, the cadence of our work shifts. We see a friction between the “Deep Time” often championed by seasoned leaders, rooted in legacy, patience, and incremental growth, and …
The Schism of Time: Bridging the generational gap in the workplace
As a pain physician with over 20 years of experience treating patients with chronic pain, I hear the same plea almost every day: “Doctor, it hurts, please help.”
As an author and patient advocate, I wanted to verbalize the daily reality of chronic pain.
Chronic pain affects an estimated 24.3 percent of U.S. adults (approximately 60 million people) as of 2023, with 8.5 percent (about 21 million) experiencing high-impact chronic pain that …
Chronic pain management: Balancing relief and regulation
I walked through a beautiful hallway the other day, the kind hospitals and clinics seem to favor now, polished floors, warm lighting, and old oak paneling on the walls. It looked less like a medical building and more like the lobby of a boutique hotel. At the end of the hallway sat a receptionist who was having a bad day. Or maybe she was just doing her job. She glanced …
Why modern medicine feels more like a bureaucracy than a profession
A false accusation or unfair allegation can destroy a doctor long before any court delivers a verdict. That is the part the public rarely sees. A charge alone can shatter a medical career. It can trigger suspension, isolation, gossip, media exposure, loss of referrals, financial collapse, and permanent reputational injury. In many cases, the accusation becomes the punishment. The acquittal verdict arrives later. By then, the damage is already carved …
Why false accusations against doctors destroy careers
An excerpt from Lessons Learned: Stories from Dual Physician Marriages, published by the American Association for Physician Leadership (AAPL), is available in print and eBook at Amazon and the AAPL bookstore.
How do two people build a strong marriage while both are practicing physicians? Medicine is demanding, and marriage can be too. Plenty has been written about how those pressures can strain relationships, but far less …
Dual physician marriage: stories of love and partnership in medicine
I just signed my first attending contract.
It should feel like pure celebration. Mostly, it does. But it is also a moment that forces reflection. For first-generation physicians, the hardest part of the journey often is not medical school or residency. It is learning how to navigate what comes after, inside systems we were never born into.
You are just as capable, compassionate, and prepared as anyone else. You have worked harder …
First-generation physician: Navigating the first attending contract
An excerpt from NOMERGENCY: Reclaiming Focus and Calm from False Urgency.
Your heart plummets.
It’s 4:55 p.m., five minutes until freedom, five minutes until you’re finally out the door to go and try that restaurant your friends have been raving about for months. But you’ve already caught a glimpse of the new e-mail from your boss, and it cannot be unseen.
The subject line reads: “Take a quick look?”
Your stomach twists.
Maybe I …
Workplace boundaries: How to stop answering e-mails at 5 p.m.
I called my old professor the other day to ask a very specific question about the Geriatric Depression Scale and expressed to him a big frustration on my end on how we are no longer able to perform such complex assessments among our patients, especially in primary care. During residency, we are taught to take thorough histories and perform physical exams by the book, but in reality, it is very …
The lost art of connection: Why medicine needs to slow down
For years, the U.S. has felt the impact of ever-rising health care costs while facing decreasing access, affordability, and worsening clinical outcomes, as compared to other countries. Multiple disruptive forces increasingly plague our health care system, our workforce and workplaces, health care facilities, health care consumers, …
The health care economic crisis: Why the system is failing in 2026
Consider a common scenario. A 65-year-old patient presents with intermittent chest discomfort present for several days and no prior history of heart disease, including among family members. The physical exam is unrevealing. An EKG and cardiac enzymes are negative. The clinician explains, “I do not see anything concerning. Given your age and symptoms, this is likely reflux. Let us have you wait three hours after eating before retiring for the …
Clinical communication skills: the power of structured language
I have spent years watching the development of quality programs. What began as a way to ensure patient safety has gradually given way to an independent group of individuals whose job it is to interpret regulations and monitor those interpretations. In the process, the clinical richness of medicine has been lost. Judgment, narrative, and context matter less than forms and metrics. The work has shifted away from the bedside and …
The 9 laws of health care quality: Why metrics miss the point
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When I started working the night shift as a nocturnist straight out of residency, no one prepared me for the physical and mental toll that lifestyle would take on my body. My motivation for pursuing this job opportunity was to spend my daytime hours with my young children: twin boys and my daughter all under five years old.
Night shift work keeps hospitals running, cities safe, and essential services moving while …
Night shift health tips: How to protect your circadian rhythm
Could it be that it is not market forces that have distorted medicine but actually the fault of those who should have been integral to the evolution of the health care system, physicians? The industry has evolved based on circumstances. Government intrusion with unregulated bureaucracies and the poison of politics can now be described as the monopsony that is basic to the present market distortions. When pricing is arbitrary based …
Health care market distortion: How government intrusion hurts medicine
I play Go. Not chess. Not checkers. Go: the ancient strategy game where the objective is not to capture pieces but to claim territory. In chess, you attack. In checkers, you jump. In Go, you place. Each stone lands quietly. Each position builds on the last. The opponent is still arguing about three moves ago while the board is already decided. The board has been built one placement at a …
Securing physician autonomy with employer-sponsored direct primary care
Most medical experts in medical malpractice are influenced by bias. Yet, they produce a certificate of merit. There are many types of biases, but I concentrate on only those biases that represent a systematic distortion that directly undermines the reliability of certainty in data and are measured by Type I and Type II errors.
Under this circumstance, merit can be regarded as certainty minus those biases. Those biases are selection bias, …
The mathematics of merit: Quantifying bias in medical malpractice
Medicine is a field defined by constant evolution. Advances in technology, groundbreaking research, and shifting patient expectations continually reshape the landscape of health care. As physicians, we are entrusted with providing excellent care. But we must also ensure that our knowledge, skills, and approaches remain at the forefront of this ever-changing environment. Staying up to date isn’t just a professional obligation, but a necessity to remain effective and relevant in …
Medical relevance and evolution: Why physicians must reinvent themselves
I hold medical licenses in multiple states. As a teleradiologist, I have to; it is the nature of the work. What I did not fully anticipate was how much time I would spend navigating the patchwork of continuing medical education (CME) requirements that vary significantly from state to state.
The variation in numbers
In Montana, the state requires exactly zero hours of CME for license renewal. Drive across the border to Washington, …
Navigating the patchwork of CME requirements by state
Most clinicians can recall a visit that technically went well, and still didn’t feel finished.
The history was taken. The exam was appropriate. High-risk diagnoses were reasonably excluded. The plan followed guidelines. The note was clean. The visit ended on time.
And yet, something lingered. Not alarm. Not guilt. Something quieter and more familiar.
We rarely talk about this state in medicine, even though we encounter it daily. We have names for missed …
Unfinishedness in medicine: When a good visit feels incomplete
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