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A patient says her hip has hurt for a while. Whether she leaves trusting her doctor depends on what happens next. Alan P. Feren, a retired surgeon, health care …
Why patients stop trusting doctors who listened to them [PODCAST]
Most of us have a well-rehearsed speech for patients with elevated blood sugar. We talk about the heart. The kidneys. The eyes. The feet. We walk through the whole organ-by-organ checklist a glucose reading can quietly damage over the years. What most of us, myself included, haven’t been saying nearly often enough is anything about the brain, and a study published this summer in Molecular Psychiatry is a good reason …
Blood sugar and brain aging start long before diabetes
If you take Ozempic, Wegovy, Mounjaro, or Zepbound, or you are simply trying to make sense of GLP-1s (glucagon-like peptide-1) and GIPs (glucose-dependent insulinotropic polypeptide), you may have seen a recent Medscape article asking whether GIP really adds any benefit in type 2 diabetes. It is a fair scientific question. The problem is that the headline makes the answer sound much clearer than it is.
The study behind the article, …
What did the tirzepatide study actually test?
There is a conceptual inconsistency in contemporary medicine that I have become increasingly unable to reconcile. Psychiatry recognizes psychic pain as a genuine clinical phenomenon, and suicidology has long recognized unbearable psychological pain as integral to suicidal states. Neuroscience has simultaneously demonstrated that nociception, affective pain, reward, motivation, salience, stress responsivity, and emotional regulation are interconnected biological processes.
Yet when psychic pain becomes intolerable, psychiatry has remarkably little therapeutic infrastructure directed …
Why is psychic pain treated as a symptom instead of pain?
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?
Ask an independent practice owner who handles the revenue cycle and the answer is usually the name of a billing company. Ask what that company actually does each month and the answer gets shorter. Claims go out. Payments get posted. Denials get worked. Statements get mailed. That is medical billing, and it is valuable work. It is not the same thing as managing the revenue cycle, and the space …
Revenue cycle management is more than medical billing
Health care has never had more data. The industry generates approximately 30 percent of the world’s data volume, and that share continues to grow faster than nearly every other industry. Electronic health records, claims systems, pharmacy records, lab results, care management notes, social determinants of health data, wearable devices, and patient-generated information are producing an unprecedented volume of information about the patients we serve.
At the same time, health care …
Why AI fails in health care: Your data is the problem
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A patient came in with weight gain nobody could explain. Every test came back fine. Shiv K. Goel is a board-certified internal medicine and functional medicine physician. This episode …
Some relationships work like medicine. Others work like a diagnosis. [PODCAST]
As an incoming fifth-year dental student beginning my clinical internship at Tamale Teaching Hospital, the major tertiary referral center for northern Ghana, I expected to refine my surgical hand and master diagnostic pathology. The fine instructors at the department made this possible, but I also got to witness firsthand the brutal arithmetic of health care access in the northern parts of Ghana.
She first presented to our oral and maxillofacial …
Cancer care in Ghana: Poverty is the true malignancy
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
Walk into any exam room today, and you’ll find more than a conversation between a clinician and a patient. Behind every visit is a steady stream of digital interactions: marketing messages, electronic health record (EHR) alerts, patient portal messages, pharmacy notifications, clinical decision support prompts, and administrative tasks, all competing for a clinician’s attention. Health care professional (HCP) media is more than just banner advertising; when delivered thoughtfully, it is …
Digital noise in health care is fragmenting clinical focus
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
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The hidden agenda of medical school curricula is loud and clear: Acuity equals status. Students are taught that the “best and brightest” belong in the windowless trauma bays of the ER or the high-pressure theaters of the OR. In this antiquated hierarchy, sleep medicine is often paternalistically patted on the head and labeled a “lifestyle” specialty, the medical equivalent of a quiet retirement.
It’s time to call out this misconception. As …
Why choose sleep medicine as an intellectual frontier
In community interventional psychiatry practices, the typical referral looks the same week after week. The patient is in the fifth or sixth year of a major depressive episode and carries a list of four, five, sometimes seven antidepressants they have “failed.” They are finally sent for transcranial magnetic stimulation (TMS) or esketamine (Spravato) long after the point when those treatments would have done the most good. By the time the …
After 2 failed antidepressants, raise TMS and esketamine
It was bound to happen. We spent years worrying that artificial intelligence would destroy humanity because of cold, unfeeling, Terminator-style logic. We thought Skynet would look at our messy carbon-based lives, calculate our carbon footprints, and casually delete us to optimize world spreadsheet performance. We were wrong. According to a recent, mildly terrifying preprint titled “The Pain Axis: LLMs Represent Self-Directed Harm and Act to Relieve It,” AI isn’t …
An AI pain study says models would delete your photos
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A doctor cracked open an airplane emergency kit and found a sticker saying there was no epinephrine inside. Lianne Mandelbaum, president of No Nut Traveler and airline correspondent for Allergic Living, has …
Food allergies are treated differently, airline by airline [PODCAST]
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
As a young person living with chronic pain, I entered a health care system that was built to find explanations to clinical problems. That is, of course, what medicine is supposed to do. Physicians are trained to identify patterns, order tests, interpret results, establish diagnoses, and develop treatment plans. When those pieces fit together, the process can feel almost reassuring. There is a problem; there is an explanation; and there …
Believing patients with chronic pain is clinical rigor
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