One of the hardest moments in medicine is not making a diagnosis. It is not writing the prescription. It is sitting across from a patient who wants something you do not believe is right for them and knowing that whatever you say next will either build trust or break it. That moment comes every day in modern practice. A patient wants an antibiotic for a virus. A patient wants a …
How to handle clinical disagreement with patients
According to the Primary Care Collaborative, primary care accounts for roughly 5 percent of health care spending, yet it influences nearly 90 percent of downstream costs. That statistic is not a compliment. It is a diagnosis. And for a profession that has spent decades accepting influence as a substitute for economic ownership, it is long past time to read it that way. For decades, physicians …
The economic shift from fee-for-service to direct primary care
Physicians are trained, above all, to project steadiness. Long before we feel it, we learn to perform it. The lesson begins early in training. The pager goes off, a room fills with urgency, and the expectation is unspoken but unmistakable: Remain calm. Do not let uncertainty show. Do not let fear show. Patients need confidence. Teams need direction. Over time, the composure stops feeling like a performance. It becomes a …
The quiet paradox of physician mental health and medication
Cassandra saw the future. No one believed her. Medicine has its Cassandras too, clinicians who name the failures before anyone else. Their warnings are dismissed, their foresight ignored, until the damage is undeniable.
This essay is built on an AI comparison. It set my 1998 Nisonger grant beside my 2025 testimony. The themes are identical: health disparities, economic justice, ethics, listening to families. I named them then. I name them now. …
Why medicine ignores its Cassandras: a case study in health disparities
During my second year of private practice, I was still close enough to academics to miss morning conferences, but far enough along to appreciate a predictable lunch break. It was then that I had an encounter that taught me why the core ethics of medicine must remain steady, even when the patient is someone the world recognizes. It happened on a Thursday, a day when the clinic usually looked like …
A celebrity patient and the core of patient confidentiality
The patient walked into the ER obtunded, breathing deep and fast, blood sugar over 400. Classic diabetic ketoacidosis. She had been symptomatic for three days.
Three days earlier, she had asked ChatGPT about her symptoms: excessive thirst, frequent urination, fatigue. The AI told her it was “probably related to dehydration and stress” and recommended increasing fluid intake and rest. It suggested calling her doctor “if symptoms don’t improve in a few …
The sensing gap: Why medical AI misses critical diagnoses
Oh, how I remember this well: The wicked snowstorm that paralyzed many cities, year after year. I was driving my van to work as it slid on black ice and directed me down a hill towards a large church. I had no control and could only pray that I didn’t hit that large telephone pole. When my van finally came to a stop, I realized I had missed the telephone …
Essential personnel safety: the hypocrisy of hospital snow policies
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Physician and health care consultant Harvey Castro discusses his article “ChatGPT Health in hospitals: 5 essential safety protocols.” Harvey outlines the immense potential of large language models to reduce administrative burdens while …
Hospitals must establish safety guardrails before deploying AI [PODCAST]
There is a kind of discipline that develops quietly over time, shaped not by certainty, but by persistence. I often think of it as the Mamba Mentality: a commitment to steady improvement, resilience, and focus on the process rather than the outcome.
For many immigrants, this mindset is not aspirational. It is necessary.
My own journey reflects this reality.
Before coming to the United States in 2007, I spent one year in the …
The Mamba Mentality of an immigrant physician’s journey
Over the past two decades, hospital systems have increasingly acquired physician practices, arguing that integration improves care coordination, lowers costs, and stabilizes struggling practices. In reality, this consolidation has often produced the opposite effect: higher costs, reduced physician autonomy, diminished innovation, and care that is less responsive to patients’ needs. While hospitals and physicians must collaborate closely, ownership is not collaboration, and hospital systems should not be in the business …
Why hospitals shouldn’t own physician practices: 6 key reasons
I’d rather be a sex worker than practice medicine in this broken system (and I’m 53, menopausal, and retired from my hot years).
Let me be clear: This is not a whimsical “maybe I will pivot into OnlyFans” moment. I am 53 years old. I am menopausal. My libido is in witness protection. The bloom is not just off the rose, the whole damn bush was yanked out and replaced with …
Why does sex work seem like a more viable path than medicine in 2026?
The world has slipped out of rhythm,
like a clock knocked from the wall
that still insists on ticking,
though the hours no longer agree.
Nothing aligns with the way it lived
in my body a year ago.
Then, there was a sense of ballast.
Morning came without dread
clinging to its edges.
I could rise,
place my feet on the floor,
and believe, perhaps naively,
that the ground would hold.
I believed the voices we chose would,
at minimum, remember us.
That disagreement was …
Finding balance in political turmoil: a poem on resilience
I cannot recall the first time my name was mispronounced; that is the point. It happened so often that no single moment stands out. The sounds were altered to make them easier. In first grade, a boy loudly said my name sounded like “cereal.” I disliked it but did not tell a teacher. Early on, I learned how others would value attributes like skin color, regardless of my permission.
When adults …
Names as social texts: Navigating cultural identity in medicine
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Psychiatrist, internist, and addiction medicine specialist Muhamad Aly Rifai discusses his article “Unregulated botanical products: the hidden risks of convenience store supplements.” Muhamad explores the dangerous misconception that “natural” equals safe, revealing …
Unregulated botanical products pose hidden risks in convenience stores [PODCAST]
My eyes opened with the familiar heaviness of a Monday morning, and as I began to pull myself out of bed, I felt a shooting pain in my neck. I was alarmed, but not wanting to be too dramatic, I repositioned on my side, pushed off and got to my feet, struggled to put a dress on without moving my neck, and headed to class. Finding that the painless range …
What neck pain taught a medical student about patient trust
For half a century, the “gold standard” of labor safety has been a single, flickering line on a screen. But as recent reporting confirms, that line is often a lie. Our obsession with isolated fetal heart rate patterns has created a surgical “false positive pipeline,” driving C-section rates to historic highs without actually reducing the incidence of cerebral palsy.
The myth of the “failed” test
The skepticism surrounding EFM often stems from …
Artificial intelligence and the future of fetal heart rate monitoring
“Mom says she talks to me every day now.”
The son told me this during a clinic visit. His 82-year-old mother, once painfully lonely, now smiled again. She told everyone she spoke with her son every morning. He asked about her day. He reminded her to take her medication. He listened to her stories.
There was only one problem.
She was not talking to her son. She was talking to an AI voice …
The hidden dangers of AI voice assistants in elder care
Even with all the incredible advances in medicine over the past 70 years, there remain severe deficits in the care of many serious deadly diseases. Pancreatic cancer, multiple sclerosis, glioblastoma, Alzheimer’s, ALS, and ovarian cancer easily come to mind in that desperate category.
However, let’s get a perspective of what it was really like to practice medicine a hundred years ago. What kind of doctors were there? What did they do? …
Medicine in 1926: What being a doctor was really like
An excerpt from In Search of Dignity: A Lifetime of Reflections.
Several years before her death at the age of 55 years due to complications of cerebral palsy, my sister Ellen was again in hospital, this time in intensive care and on the brink of respiratory collapse. To say cerebral palsy had shaped her life is an understatement, in that it molded nearly every facet of her being, from the …
The Platinum Rule in health care: Moving beyond the Golden Rule
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Internal medicine physician Shiv K. Goel discusses his article “Claude for Healthcare vs. administrative burden: a physician’s review.” Shiv contrasts the two hours he spent fighting a prior authorization with the promise …
AI could end the administrative nightmare for doctors [PODCAST]
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