Timothy Lesaca, MD

How to practice civility in medicine

How to practice civility in medicine

July 9, 2026Jul 9, 2026

"Labour to keep alive in your heart that little spark of celestial fire called conscience." - Rule 110 from Rules of Civility, copied by George Washington as a teenager The most consequential gesture in a clinic visit is sometimes the…

“Labour to keep alive in your heart that little spark of celestial fire called conscience.”
– Rule 110 from Rules of Civility, copied by George Washington as a teenager

The most consequential gesture in a clinic visit is sometimes the smallest one: a hand resting on the door handle. The visit seems over. The plan has been explained, the orders are in, and the day is already running late. Then, as you …

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Adaptation to illness matters as much as the diagnosis

July 3, 2026Jul 3, 2026

Picture two patients seated in the same waiting room, hearing the same diagnosis from the same physician on the same day. From that moment, their lives diverge, each setting out on a journey shaped by individual choices, relationships, and ways…

For one patient, the diagnosis becomes a consuming shadow. Every ache signals a smaller world. Fear and anger begin to strain relationships that were once strong. Work no longer …

Racial bias in schizophrenia diagnosis must end

June 28, 2026Jun 28, 2026

A young Black woman waits in a psychiatric emergency room. She is grieving, traumatized, and depressed. The clinician, however, describes her as "guarded," "hostile," and "paranoid" in the chart. She leaves with a schizophrenia diagnosis, a prescription for a first-generation…

A young Black woman waits in a psychiatric emergency room. She is grieving, traumatized, and depressed. The clinician, however, describes her as “guarded,” “hostile,” and “paranoid” in the chart. She leaves with a schizophrenia diagnosis, a prescription for a first-generation antipsychotic, and a future shaped by a label she should never have received.

This is not a hypothetical situation. The Harvard Review of Psychiatry documented this case in 2023. She was …

Health policy

When a health insurance denial leads to death

June 23, 2026Jun 23, 2026

For generations, the struggles between patients and health insurers have played out in the quiet corridors of bureaucracy and the echoing halls of the courts. When a claim is denied, the journey that follows is often a weary procession: appeals, reviews, complaints, and lawsuits. Even when an insurer is found at fault, the reckoning is almost always measured in a payment here, a penalty there, and maybe a sanction filed …

Health technology

Why the safest medical AI knows when not to answer

June 17, 2026Jun 17, 2026

When a recent study in Nature Medicine compared general-purpose AI models with specialized clinical tools, the headline was exactly the kind the technology world likes to see: The generalists came out on top. The reactions were predictable. Some observers treated…

The reactions were predictable. Some observers treated the study as proof that specialized clinical software is no longer needed, arguing that bigger and more powerful AI models will always win. Others dismissed the study, pointing out that AI …

When a patient attacks you, it changes your life

June 11, 2026Jun 11, 2026

I did not intend to visit an emotionally dark place. But now I think I was destined to be there, to maybe find some light. Recently, I began a literature review of articles on workplace aggression toward mental health clinicians.…

I did not intend to visit an emotionally dark place. But now I think I was destined to be there, to maybe find some light.

Recently, I began a literature review of articles on workplace aggression toward mental health clinicians. It was meant to be a routine process. Instead, I became focused on research exploring how workplace violence fundamentally changes people, and how, for some, perceptions of self and others are …

The Goldwater Rule and the cost of psychiatric silence

May 31, 2026May 31, 2026

When the American Psychiatric Association formalized Section 7.3 of its Principles of Medical Ethics in 1973, it acted with a clear sense of urgency. Nine years earlier, the psychiatric profession had profoundly embarrassed itself in a partisan poll published by Fact magazine, where 1,189 psychiatrists, without any clinical examinations, labeled Republican presidential nominee Barry Goldwater “psychologically unfit.” The diagnoses were sloppy, weaponized, and defamatory.

The decayed fortress of silence

In response, the …

Violence against doctors: 5 forces that ignite it

May 30, 2026May 30, 2026

You might recall the 2002 film John Q., in which a desperate father takes a hospital emergency room hostage because his insurance company refuses to cover his son's heart transplant. It is a gut-wrenching depiction of medical rage. But now…

You might recall the 2002 film John Q., in which a desperate father takes a hospital emergency room hostage because his insurance company refuses to cover his son’s heart transplant. It is a gut-wrenching depiction of medical rage. But now looking back at that scenario from the vantage point of 2026, the moral direction of that anger feels fundamentally different from what physicians face today. John Q. was furious at …

Why physicians miss business owner stress in patients

May 20, 2026May 20, 2026

The ECG was normal. The troponin was negative. The stress test was reassuring. Yet the patient in front of you looked as if he had been living under siege for months. He was not sleeping. His blood pressure had worsened,…

The ECG was normal. The troponin was negative. The stress test was reassuring. Yet the patient in front of you looked as if he had been living under siege for months.

He was not sleeping. His blood pressure had worsened, despite medication adherence. He described chest tightness, reflux, headaches, irritability, and difficulty concentrating. He woke most nights around 3 a.m., his heart beating fast, checking an account balance, and then lay …

Medical apology laws don’t reduce malpractice lawsuits

May 15, 2026May 15, 2026

An apology after medical harm still matters, but perhaps not for the reasons medicine once believed. For a long time, medicine saw apologizing after a bad outcome as risky or, at best, a way to protect oneself. Doctors were told…

An apology after medical harm still matters, but perhaps not for the reasons medicine once believed.

For a long time, medicine saw apologizing after a bad outcome as risky or, at best, a way to protect oneself. Doctors were told to say as little as possible: Avoid guessing, don’t admit fault, and don’t apologize. This made sense in a legal system where lawsuits are common. But after a serious mistake, staying …

What hidden constraints shape clinical decisions?

May 6, 2026May 6, 2026

What if the biggest problem in medicine isn't bad decisions but rather the decisions we cannot even consider? Clinical decisions unfold through processes shaped by the environment, which determine what clinicians can notice, consider, and act on. What seems like…

What if the biggest problem in medicine isn’t bad decisions but rather the decisions we cannot even consider?

Clinical decisions unfold through processes shaped by the environment, which determine what clinicians can notice, consider, and act on. What seems like individual reasoning is structured in advance by systemic and environmental forces.

Within this context, this paper introduces a concept that I call “invisible triage,” a preconscious process that restricts which options are …

Pilot mental health is a safety issue, not a stigma

April 28, 2026Apr 28, 2026

You know what it feels like to keep working and pushing yourself when you are tired, distracted, or maybe even burned out. It's common across professions, and we rarely speak about it openly. We almost never think of it as…

You know what it feels like to keep working and pushing yourself when you are tired, distracted, or maybe even burned out. It’s common across professions, and we rarely speak about it openly. We almost never think of it as a safety issue. But for airline pilots, that silence can put hundreds of lives at risk.

That is why I believe this belongs in a conversation among clinicians. Medicine is often …

Therapeutic alliance in psychiatry matters more than ever

April 22, 2026Apr 22, 2026

Each May, during Mental Health Awareness Month, the health care industry releases its usual statements about access to care, workforce stress, and the enduring shadows of stigma. I usually read them between back-to-back appointments, staring at a screen full of diagnostic codes. The systemic issues are always important, yet, amidst the charts, the 20-minute med checks, and the rhetoric, there remains a more profound question I have to ask myself …

Pharmacy closures threaten our entire public health system

April 13, 2026Apr 13, 2026

We turned pharmacies into the backbone of public health during coronavirus disease 2019 (COVID-19). Then we went back to paying them like retail stores. The result is what I think of as the pharmacy paradox. We expanded their role without changing the economics that sustain them. Now, across the country, those same pharmacies are closing, quietly and disproportionately in the communities that need them most.

In 2021, the corner drugstore ceased …

The second victim label ignores patient safety reality

April 10, 2026Apr 10, 2026

Ask any clinician about the drive home after a case goes bad and the patient outcome is tragic. It is a specific kind of heavy silence. We have all had the experience. You do not forget it. You replay the tape in your head dissecting every move, carrying a stain that does not wash off or show mercy. It owns you.

We have had a name for this for 20 years: …

Why physician neutrality in the face of harm is a choice

April 2, 2026Apr 2, 2026

These moments of hesitation keep happening to me. I recognize the harm. I can name it clearly. I have seen its effects over and over again with my patients. And yet, when the conversation turns to its cause, I hesitate. Not because I do not understand. Because I am supposed to stay neutral. Medicine has long held neutrality as a professional virtue. We are taught to rise above politics, to …

Why physician burnout is actually a loss of professional identity

March 28, 2026Mar 28, 2026

Most accounts of physician burnout begin with a familiar list: too many hours, too many clicks, too many patients, and not enough time. The diagnosis follows easily. Doctors are exhausted. Something inside them has been used up. Burned out. That explanation has the advantage of being familiar. It also has the potential to be incomplete. There is another way to understand what is happening, one that comes from an unlikely …

The hidden math behind physician hiring costs and recruitment

March 18, 2026Mar 18, 2026

Most physicians know what they earn. Far fewer know what it costs to hire them or replace them. A colleague once told me in frustration, "It takes me two years to get my money back on a new hire." I…

Most physicians know what they earn. Far fewer know what it costs to hire them or replace them. A colleague once told me in frustration, “It takes me two years to get my money back on a new hire.” I understood the frustration, but not the math. I thought of hiring the way many physicians do: salary, benefits, maybe a signing bonus. It seemed straightforward. It is not. Hiring a …

The quiet paradox of physician mental health and medication