She arrived in my emergency department in police custody around three o’clock, with legal documentation holding her, against her will, for an emergency psychiatric evaluation. The officer reported a chief complaint of suicidal ideation. The patient and her husband adamantly denied this, and her husband wanted to take her home.

The patient and the officer both told me the same story. Earlier in the evening, the patient had been playing an online video game on her laptop. She shared a group chat with online friends. Someone in the chat wrote something vaguely suicidal, and the patient read it.

More importantly, the patient’s computer read it. A ping was sent to her employer, by way of device management software installed on that computer by her company. Someone in HR called 911, the police were dispatched, and the patient was woken up and brought to the ER.

The officer knew there was nothing wrong with her, but told me apologetically that he was obligated by his departmental policy and his superiors to fill out the paperwork and bring her in. I reversed the psychiatric hold and discharged her home, having done nothing for her other than disturb her sleep.

Nothing about that night is remarkable. I have written many essays about the policies that produce nights like these but have never written down the nights themselves.

My long-form essays dissect the policies that have ruined American healthcare. They are technical and well researched. They make principled and empirical arguments for free market solutions to what I think are largely government-created problems. The truth, though, is that I did not and still do not think about these problems from a dispassionate, rational, twenty-thousand-foot view. I did not arrive at my conclusions from a cold and detached review of the evidence, at least not at first. Like any human being, my thinking is shaped by my circumstances and is molded more by their emotional impact than I often care to admit. I see, and I feel, what happens to me and to my patients on shift. It hits me in the gut. It angers me. Enrages me, actually.

My newsletter was born to try to make sense of that anger. I started writing because the anger was leaking out into the rest of my life. Turns out it still does; I just articulate it better now. I thought that if I started writing essays about what happens to me and to my patients, and more importantly why it happens and what I think we can do about it, I’d be better able to leave work at work and separate out my personal life. The trouble is that my work is deeply personal. Try as I might to compartmentalize and detach, each patient I see is a person.

My essays explain the principled arguments for what I think would fix healthcare, but lately I think it’s also important to simply show you what my shifts are like. You can read the arguments and understand them and agree with them, but you can’t know the impact or even the true genesis of the arguments without experiencing emergency medicine day in and day out.

In these new monthly dispatches, I won’t be making any arguments. There won’t be any data and figures, and there won’t be any citations or numbers. Instead these dispatches will each be a collection of vignettes and experiences, told from my perspective, as they happened to me and to the patients I was treating.

I can’t tell you when or where I worked these shifts, nor who the patients are. Each dispatch represents one single shift but is in fact a blend of stories from the many shifts I’ve worked throughout my career, with key patient details changed for privacy. These stories are not extraordinary. Any given dispatch will not be a concatenation of the worst experiences of my career, made to appear to be one nightmare shift. I will not cherry-pick and I do not aim to exaggerate. I aim to show you the unembellished reality of my job and nothing more. There will be no heroics, no tidy endings, and no preached morals or concluding lessons.

These dispatches will be released on the first of every month to paid subscribers. The free long-form essays that come every two weeks will remain free forever. They stay free because the dispatches pay for them. Thank you in advance to anyone who supports my work, and if you know someone who would recognize these stories, please send this to them.

I believe the arguments in my long essays are vital, but they can be made by anyone willing to research the topic. What actually happens in the ER at two thirty in the morning cannot.

Faithfully,

Julian Galt, MD

Some background is necessary here, because Medicare’s method of paying physicians is unfamiliar even to people who have been its beneficiaries for years. Medicare does not negotiate with doctors. It sets the price of every service in medicine by formula, published each year in a document called the Physician Fee Schedule. Each of roughly ten thousand billable services carries a numerical score meant to capture three separate things: the physician’s own labor and judgment, the overhead required to deliver the service, and the cost of malpractice coverage. That score is then multiplied by a single dollar figure called the conversion factor, which is the same for every service and every specialty in the country. The consequence of building a system this way is that a small adjustment to any one component moves thousands of prices at once. A further constraint compounds it. By statute the schedule must be budget neutral, meaning that any increase in what one service is worth has to be paid for by reductions in what others are worth. At no point does a patient’s willingness to pay or a physician’s willingness to accept enter the calculation. The price is set by committee and revised by rule, and the only question each year is which direction the rule moves it. In real terms, that direction has been remarkably consistent year after year for over 25 years: down.

The particulars of this year’s rule are worth setting out plainly, because the arithmetic gets buried quickly. For calendar year 2027, CMS proposes conversion factors of $33.17 for physicians who qualify as participants in advanced alternative payment models and $32.84 for everyone else, representing reductions of 1.19 percent and 1.68 percent respectively from the 2026 figures.2 Because that figure touches every service, a reduction in it is a reduction in the price of everything a physician does.

This follows a year in which two other changes were finalized and took effect on January 1, 2026. The first is what CMS calls an efficiency adjustment, a 2.5 percent reduction applied to two of the inputs described above, the units representing the physician’s own labor and the agency’s estimate of how long the service takes to perform, for all services that are not billed by time.3 That category is essentially every procedure, every imaging study, and every diagnostic test. The agency’s justification is that the survey data underlying its time estimates suffers from low response rates and from the conflicts of interest inherent in asking physicians how long their own work takes, and that the resulting figures are therefore probably inflated.

The second change is more easily misunderstood, and it requires a word about how a hospital gets paid. When a physician performs a service in his own office, Medicare makes one payment, meant to cover both his professional work and the overhead of the room he works in. When the identical service is performed inside a hospital, Medicare makes two payments: a smaller professional fee to the physician, on the theory that he is not the one paying for the room, and a separate facility fee to the hospital under an entirely different payment system with its own annual rule. The professional fee has always been lower in the hospital. The combined total has almost always been higher, and frequently by a great deal. Medicare pays on the order of two to four times more for many identical outpatient procedures performed in a hospital outpatient department than in an independent physician’s office.4

What CMS finalized for 2026 does not touch the facility fee. It cuts the physician’s portion. The agency halved the overhead allowance built into professional payment for services delivered in a facility setting, reasoning that so few physicians now maintain private offices that the old assumption no longer describes how medicine is practiced.5 Because the change is budget neutral, the savings do not return to the Treasury. They are redistributed to physicians working outside hospitals. The American Medical Association calculates the resulting shift at roughly seven percent downward for services performed in facilities and four percent upward for services performed outside them.6 CMS titled this provision a site of service payment differential, which invites the reader to hear site-neutral reform. It is closer to the opposite. Genuine site neutrality reduces what the hospital collects for the use of its building. This reduces what the physician collects for working inside it, and leaves the building’s fee precisely where it was. The money moved from hospital-based physicians to office-based physicians. It did not move from hospitals to physicians.

There is a circularity in the justification. CMS reasons that facility-based physicians no longer require an overhead allowance because so few physicians remain in independent practice. That is accurate as a description of the present. It is also a condition that the payment system produced, in no small part through the very facility fee differential that allowed hospitals to outbid independent practices for identical work. The agency is citing the consequence of its own pricing as grounds for a further reduction. And the reduction falls with particular force where no alternative setting exists. An emergency physician has no non-facility option available to him. The emergency department is a facility by definition, so he absorbs the seven percent and can never reach the four.

Layered on top of the payment changes is an expansion of regulatory obligation. Traditional participation in the Merit-based Incentive Payment System is to be phased out in favor of mandatory Merit-based Incentive Payment System Value Pathways, with the older system sunset by 2029.7 Separately, CMS has already launched the WISeR model, a six-year demonstration that introduced machine-assisted prior authorization and prepayment review into traditional Medicare beginning in January of this year across six states.8 Participation is nominally voluntary, but physicians who decline to seek prior authorization are subjected to automatic prepayment review instead, which is a distinction without much practical difference. Medicare beneficiaries have historically been spared the prior authorization apparatus that governs commercial coverage. That exemption is now ending, and it is ending under an administration that campaigned against prior authorization as a commercial abuse.

All of this sits on a longer trend. The American Medical Association, working from Federal Register data, Medicare Trustees reports, and federal inflation statistics, calculates that Medicare physician payment declined 33 percent in real terms between 2001 and 2025 once the inflation in practice costs is accounted for.9 Physician services remain the only major category of Medicare spending not indexed to inflation. Hospitals receive an annual update tied to their input costs. Ambulatory surgical centers receive one. Medicare Advantage plans receive one. Physicians receive a statutory 0.25 or 0.75 percent, and then whatever the budget neutrality calculations do to them afterward.

That figure deserves a qualification its partisans rarely supply. MedPAC, examining the same stretch of years, confirmed the gap: the conversion factor stood at $36.61 in 2000 and $33.89 in 2023, a decline in unadjusted dollars, while the index of practice costs rose about 52 percent over the same years.10 But the same MedPAC analysis found that Medicare spending per beneficiary on fee schedule services grew roughly 101 percent over those years, because the volume and intensity of services climbed even as the price of each one fell. Total spending on physician services did not decline. It approximately doubled. Anyone who cites the inflation-adjusted figure without saying so is presenting half a ledger.

The qualification matters, though not in the direction its usual proponents intend. A payment system that holds down the price of every unit while the number of units rises is not a system that has treated physicians generously. It is a system that has quietly instructed them to work faster in order to stand still, and they have complied, which is the reason aggregate spending rose at all. That is the treadmill. The rule now under consideration adds another revolution to it.

The provision that deserves the most attention, however, is not the conversion factor. It is a proposal CMS describes as accounting for overlap between stand-alone evaluation and management visits and global periods. Two pieces of vocabulary are required to follow it. An evaluation and management visit is the thinking part of an encounter, the portion in which the physician takes a history, examines the patient, and works out what is wrong. A global period is a window of time following a procedure, ranging from zero to ninety days depending on the procedure, during which any related follow-up care is treated as already bought and paid for by the original fee.

Under the proposal, when a physician performs a distinct office or outpatient visit on the same day as a procedure carrying such a period, the most expensive of the services is paid in full and every other service furnished that day is paid at half rate.11 In plainer language, a physician who sees a patient in the office, determines that he needs a procedure, and performs it that same day will only be paid half the price of either the procedure or the evaluation. The agency’s reasoning is that when the same physician evaluates a patient and then performs a procedure on that patient in the same encounter, some of the work is shared, and paying separately for both therefore compensates the physician twice for a single effort. CMS proposed something similar in 2019 and did not finalize it. It has now returned.

The observation underlying the proposal is not false. There is overlap. A physician who examines a shoulder and then injects it has not conducted two independent examinations, and the history he takes serves both purposes at once. Anyone who has watched the modifier that designates a separately identifiable visit be applied with enthusiasm knows the agency’s concern was not manufactured out of nothing. If some physicians bill dishonestly, though, that is an argument for enforcing the rules against those physicians. It is not an argument for repricing the work of the ones who don’t. And notice what the agency does with its observation. It reasons that because less work went into the second service, the second service is worth less, and it then proceeds to calculate how much less. That inference is the whole of the policy, and it is mistaken at the root.

The price of a thing is not determined by the effort poured into it. The contrary belief, that a good’s worth derives from the labor embodied in it, is the Labor Theory of Value, and it was among the more consequential errors of nineteenth century economics. It was answered in the 1870s by Carl Menger and the school that grew up around him. Value is not a property residing inside an object or a service, waiting to be recovered by an auditor with a stopwatch. It is a judgment, made by the person who wants the thing, about what having it is worth to him. Ludwig von Mises stated the matter about as plainly as it can be stated: value “is not intrinsic, it is not in things.”12 A shirt sold under a luxury label and a shirt sold by a discount retailer may be cut from the same cloth in the same factory by the same hands, and they will never command the same price, because a price does not report the conditions of manufacture. It reports what someone will pay.

The rest of the economy conducts itself accordingly. A mechanic who replaces the brakes and the alternator in one appointment does not bill half for the second repair on the grounds that the car was already on the lift. A barber who cuts a man’s hair and colors it in the same sitting does not charge half for the cut. It is fair to object that a mechanic sometimes will discount the second repair, and that salons sell packages priced below the sum of their parts, and the objection deserves an answer rather than a dismissal. The answer is that such a discount is offered, not imposed. It emerges from a negotiation between a seller who knows his own costs and a buyer who knows what the work is worth to him, and it comes to rest wherever the two of them consent. Nobody computes it, and nobody else is bound by it. What CMS proposes is not a discount but a finding: an official determination, binding on every physician in the country, that the second service is worth exactly half. A negotiated price and a calculated one are not the same kind of thing, and the difference between them is not one of degree.

This is why the particular figure is nearly beside the point, though it is worth noting that fifty percent is not a measurement of anything. It is a round number. No study established that the shared work between an evaluation and a procedure amounts to half the value of the lesser service, and no study could, because the sharing differs in every pairing the rule would govern. The overlap between an office visit and a skin biopsy is not the overlap between an office visit and a complex wound repair. But a perfectly measured figure would not rescue the policy either, because the measurement answers a question that has nothing to do with price. Every instrument in the fee schedule is an instrument for measuring inputs. Work units measure time and intensity. The efficiency adjustment measures assumed productivity. This provision measures assumed duplication. Nowhere does the apparatus ask what the service is worth to the person receiving it, and it cannot ask, because that person is not paying for it and is not permitted to decline it at the stated price. There is nobody in the transaction whose refusal would mean anything.

It is telling that the agency justifies its efficiency adjustment by declaring its own time data unreliable, and then, having discredited its measurements, responds not by measuring more carefully but by applying a different unmeasured number in the opposite direction. If the inputs cannot be trusted, the remedy is not a more confident guess about the inputs. The deeper trouble is that the inputs were never the thing worth looking at. A payer able to observe prices would have no need to compute them.

The consequence in outpatient practice is entirely foreseeable, and it is the opposite of what the rule intends. Consider a physician who sees a patient for a new complaint, determines that a procedure is warranted, and can perform it that afternoon. Under current payment he does so. Under the proposed rule, performing it that afternoon costs him half the value of one of the two services. Deferring the procedure to a separate appointment costs him nothing. He is not required to defer, and the vast majority of physicians will not defer where deferral would harm the patient. But most of these procedures are not urgent, deferral is clinically defensible in the ordinary case, and the physician who schedules a return visit can give an entirely honest account of why he did so. He wants to think it over. He wants the patient to consider the options. The schedule that day was full. Every one of those statements can be true, and the payment rule will have made all of them more likely to be uttered.

This is not an accusation of fraud but merely a description of how prices work. Prices communicate information to sellers. A price that penalizes doing two things at once will produce fewer instances of doing two things at once. The physician responding to that signal is doing what the payer’s own price structure instructs him to do. The result is that the patient who could have been finished in one afternoon now makes two trips, pays two facility fees or two copayments, takes a second day away from work, arranges a second ride if he does not drive, and waits however long the schedule requires with his problem unresolved. Medicare pays for two encounters where it previously paid for one and a half. A rule adopted to eliminate duplicative payment will have manufactured genuine duplication, and will have charged the beneficiary for the privilege in money, time, and delay.

The agency has precedent to consult on this point and appears not to have consulted it. Medicare has applied multiple procedure payment reductions to diagnostic imaging and to therapy services for years, reducing payment for second and subsequent services performed in the same session on the same theory of shared resources.13 Those policies generated persistent disputes about whether the assumed efficiencies were ever demonstrated, and they taught the professions subject to them to think carefully about what gets scheduled on which day. The lesson available from that history is that same-session reductions do not reduce the amount of care delivered. They redistribute it across the calendar.

As the proposed rule is literally written, the fifty percent reduction is triggered by office and outpatient evaluation and management codes. Emergency department visit codes belong to a different family and are not captured by the text as drafted, and the American College of Emergency Physicians did not identify this provision among its principal concerns in its summary of the rule. An emergency physician reading a headline about a fifty percent cut and concluding that his own billing is affected on January 1, 2027 has read too quickly.

He has not, however, read wrongly about where this is going. CMS explicitly solicits comment on whether the policy should be extended to other categories of evaluation and management visits.14 That solicitation is how these provisions arrive: proposed narrowly, finalized narrowly, and then extended in a subsequent cycle once the principle has been established and the affected specialty has already absorbed the first version. More to the point, the rationale CMS offers contains nothing that stops at the clinic door. If the overlap between an evaluation and a procedure performed in the same encounter justifies halving payment for the lesser service, that argument applies with greater force in the emergency department, not less, because in emergency medicine the evaluation and the procedure are always the same encounter by necessity. The agency has articulated a principle whose logic points directly at the setting where the conduct it describes is universal and unavoidable.

And the emergency department has no answer to it. The clinic’s response to this rule is the calendar. The emergency department has no calendar. A laceration is closed during the visit in which it presents. A shoulder is reduced when the patient arrives with it dislocated. An abscess is drained then, a chest tube placed then, a fracture splinted then. There is no version of emergency practice in which the physician evaluates a patient, identifies a procedure, and offers him an appointment. The federal government has made certain of this, having required by statute since 1986 that emergency departments evaluate and stabilize every patient who presents regardless of ability to pay.15 The same government that mandates the immediacy would, under an expansion of this policy, reduce payment for the immediacy on the theory that it represents an efficiency the physician chose to capture.

It is worth being precise about who bears that. Emergency medicine already operates on an unusual economic footing. CMS itself has historically assumed that a majority of an emergency physician’s time is uncompensated, a consequence of the obligation to treat everyone who arrives regardless of ability to pay.16 Burnout in the specialty has been measured at levels at or near the highest of any field of medicine, and the drivers identified in the literature are not the acuity of the work but the conditions surrounding it.17 The residency match in emergency medicine collapsed in 2023, when more than five hundred positions went unfilled, recovered substantially, and remains volatile in a way it was not a decade ago.18 Boarding, the practice of holding admitted patients in the emergency department because no inpatient bed is available, has been declared a crisis by essentially every organization in a position to declare one, and it converts an emergency department into an unstaffed inpatient ward while new patients continue to arrive.

Into that, add the practice expense reduction already finalized for facility settings, which the American College of Emergency Physicians objected to specifically on the ground that it misunderstands how emergency care is actually delivered.19 Then add a conversion factor cut. Then add, prospectively, a halving of payment for procedures the physician had no option to defer. The department that is already the least able to absorb a reduction is the department positioned to absorb the largest one.

The downstream mechanism is where the real damage lies, and it runs through hospital accounting rather than through physician income. Emergency departments are treated in most hospital budgets as cost centers. They consume space, staffing, and equipment, and the professional revenue they generate rarely covers what they consume. This accounting is not merely conservative. It is wrong, and demonstrably so. RAND’s study of the evolving role of emergency departments found that emergency physicians serve as the principal decision makers for roughly half of all hospital admissions in the United States.20 The emergency department is the mechanism through which the hospital acquires the inpatients on whom its margins depend. But the revenue from those admissions is booked to the inpatient service lines, while the cost of generating them is booked to the emergency department. The department that produces the hospital’s business appears on the ledger as an expense.

An administrator looking at that ledger in a year when emergency professional revenue declines does not see a specialty in distress. He sees a cost center performing worse than last year, and he responds as he has been trained to respond. Nursing ratios are adjusted. Scribes are eliminated. Technicians are not replaced when they leave. The physician group’s contract is renegotiated downward or put out to bid, and the bid is won by whoever will staff it for less. Every one of those measures slows the department down. A slower department boards longer, sees fewer patients per hour, and generates less revenue, which produces a worse number on the next year’s ledger and another round of the same reasoning. This is what happens when a budget process treats a revenue-generating function as a cost and then reduces the revenue.

A fair objection is that sophisticated health systems understand the downstream contribution of emergency volume perfectly well and model it deliberately, and some of them do. But budget authority follows the cost center, not the model, and the marginal decision about staffing an emergency department is rarely made by the person holding the systemwide analysis. Another fair objection is that emergency physicians are hospital-based and largely employed, so the professional fee schedule matters less to them personally than to an independent surgeon. That is true of the individual paycheck and irrelevant to the argument. The professional revenue still determines what the department is worth to the institution, and the institution is what determines whether there are enough people working on a Tuesday night.

The administrative burden compounds all of it. Physician practices in four common specialties were found to spend an average of 785 hours per physician each year on the reporting of quality measures, at an aggregate cost exceeding $15.4 billion.21 That study is now a decade old, and the reporting obligations it measured have not contracted. The rule under discussion adds a mandatory pathway structure and arrives alongside a prior authorization demonstration in traditional Medicare. Each of these is defended individually as a modest addition. Collectively they constitute a second occupation practiced alongside the first, and they are the principal reason independent practice has become difficult to sustain. The share of American physicians employed by hospitals or corporate entities rose from roughly a quarter in 2012 to more than three quarters by 2024.22 That is the actual downstream effect of twenty-five years of payment policy, and it is worth stating clearly what it costs. The independent practice is the exit option. It is the thing a physician can do when the terms offered become unacceptable. A profession without an exit option does not negotiate. It receives.

The deeper problem is not that CMS chose the wrong number. It is that a single number was going to be chosen at all. The agency is attempting to set thousands of prices for hundreds of millions of encounters occurring under conditions it cannot observe, using survey data it has publicly declared unreliable, subject to a budget neutrality requirement that makes every increase somewhere a decrease somewhere else. The arrangement is working exactly as an arrangement of that kind must.

Prices in a market are not measurements taken by an observer; they are the output of countless people revealing what they will actually pay and actually accept. Remove the paying and the accepting, and no amount of methodological care recovers the information, because the information was never sitting somewhere waiting to be gathered. It is generated by the transaction or it does not exist. The physician who has spent two decades watching his reimbursement fall while his costs rise is not the victim of a miscalculation. He is watching a system that has no mechanism for discovering that it is wrong. Keith Smith, who founded a surgical facility in Oklahoma that has posted its all-inclusive prices publicly since 2009 and accepts no insurance, has put the point more economically than I can: imposed prices are always wrong.24 Too high or too low, but never accurate, because accuracy is not a property that administered prices are capable of having.

Budget neutrality makes the pathology explicit. Because every increase must be offset, the specialties do not compete to attract patients. They compete against one another for shares of a fixed pool, in front of the same committee, with the same lobbyists. Cardiology’s gain is oncology’s loss by regulatory arithmetic rather than by anything either of them did for a patient. A system that pitted grocers against one another this way, holding total grocery revenue fixed and adjudicating the split annually in Washington, would be recognized immediately as absurd.

I should be candid about where I stand. I think Medicare should not exist. I think the same of Medicaid, and of most of the regulatory apparatus assembled around them, and my objection is not primarily a fiscal one. It has to do with what it means to compel a man into an arrangement across the whole of his working life and then set the terms of his participation by rule, revised annually, with his only recourse a comment period. That is the subject of another essay and a longer one, and I will not pretend to have made the case here.

I raise it only in order to set it aside, because the reform I want to argue for requires no one to accept any part of it. Take Medicare exactly as it stands, funded as it is and universal as it is, and one change remains available that needs no new program, no appropriation, and no act of political imagination. It needs the repeal of a restriction. Under current law, a physician who wishes to contract privately with a Medicare beneficiary at a mutually agreed price must opt out of Medicare entirely for two years, forgoing all Medicare payment for all of his patients, and even then may not use a private contract for emergency or urgent care.25 This is not a public program with a private market alongside it. It is a toll gate with a single setting. A physician may not accept Medicare for most of his practice and contract privately for part of it. He may not charge a beneficiary who would gladly pay more for more of his time. The restriction has been criticized across the political spectrum as an unusual constraint on ordinary freedom of contract, imposed on a program whose participants were enrolled by the arrival of a birthday.26 Permit a beneficiary to carry a defined contribution to a physician of his choosing, at a price the two of them set between themselves, and you have created for the first time in sixty years a mechanism by which Medicare might discover what its services are actually worth.

Anyone inclined to hear in this a proposal that the elderly be left to fend for themselves should notice what is actually being asked for. Nothing is taken from the beneficiary. He keeps the benefit he has. What he gains is a permission he currently lacks, which is the right to spend his own money on a physician willing to treat him at a price the two of them agree upon. The objection assumes that the arrangement he has now is working, and this essay has spent some length explaining why the physicians on the other side of it are leaving.

That such arrangements function is not a matter of theory. Direct primary care practices publish their monthly fees and patients pay them. The Surgery Center of Oklahoma has posted its surgical prices for more than fifteen years, accepts no insurance, and draws patients from across the country who travel past hospitals nearer to home.27 These are not marginal curiosities. They are demonstrations that when a physician is free to name a price and a patient is free to refuse it, the price becomes knowable in advance, tends downward under competition, and requires none of the apparatus that consumes 785 hours of a practice’s year.

The strongest objection to all of this is that emergency care is not shoppable. The patient having a stroke does not compare prices. The unconscious patient consents to nothing and negotiates nothing. Information asymmetry, which is a manageable problem when a patient is choosing a knee replacement over several weeks, is total when he arrives by ambulance. Whatever a market can accomplish in elective surgery, it cannot be relied upon to set the price of resuscitation, so the argument goes.

This objection is generally correct about the case it describes, but it is worth noticing how small that case is. Roughly eighteen percent of emergency department visits arrive by ambulance. The other four fifths arrive by private vehicle, which is to say that the patient, or somebody sitting beside him, decided which hospital to drive to.28 When the National Center for Health Statistics studied how far patients travel to reach an emergency department, it excluded ambulance arrivals from the analysis on the express ground that those patients likely had little or no choice of which department they visited, which is a federal statistical agency stating plainly that the remainder do.29 Nor is the ambulance itself free of judgment. Crews weigh distance against capability, whether the receiving hospital has a catheterization laboratory or a stroke center or a trauma designation at the necessary level. They weigh what the patient says he wants. And they weigh, whether or not anyone says it aloud, which departments take the handoff promptly and treat the crew as colleagues and which leave them holding a stretcher against a hallway wall for the better part of an hour. Emergency departments compete already. They compete on capability, on reputation, on how the waiting room looks at nine in the evening, and on how they treat the people who bring them patients.

The insurance arrangements built on top of this give the game away. Insurers maintain networks for emergency care and negotiate rates for inclusion in them, and hospitals accept discounted rates in exchange for being included. That trade makes sense only if membership brings patients through the door, which is to say only if patients choose. Congress limited the consequences of the practice in 2021, barring balance billing for emergency services and capping what a patient owes at the in-network amount, and it did so on the stated ground that a patient in an emergency often cannot select his provider.30 But it did not abolish the networks. It moved the argument over the rate from the patient to an arbitration process, and hospitals go on paying in discounted rates for the privilege of appearing on the list. The industry’s own conduct, sustained across decades and continuing today, reflects a settled commercial belief that where a man goes for emergency care is a decision he makes. Emergency medicine is less shoppable than a knee replacement, but it is a good deal more shoppable than the objection allows.

The objection establishes that the emergency department is a poor site for price competition at the moment of a true, incapacitating medical or surgical emergency. It does not establish that administered pricing is therefore the right way to pay for it, and the evidence of the last twenty-five years is that administered pricing has served emergency medicine catastrophically.

Two responses follow, and the first requires some care, because a reader who has come this far will have noticed a tension. I do not think Congress should have written EMTALA. A statute that commands a private party to render a service and says nothing about paying him for it is a conscription, and describing the service as a right does not alter what has been done to the man obliged to provide it. The duty to treat a person who is dying in front of you is real, and it is a great deal older than the statute. Physicians and hospitals attended to emergencies before 1986 out of professional obligation and ordinary decency, and they would continue to do so without a federal command. The honest objection to that view is that they did not always do so, that patients were in fact turned away from emergency rooms for want of insurance, and that this is precisely why the law was written. I take the objection seriously. My answer is that the remedy chosen was worse than the disease, and that a mandate without money has produced a slower and more widely distributed version of the same abandonment, borne now by everyone sitting in the waiting room.

The statute exists, however, and it will not be repealed this year or next, and a position with nothing to say about the interval is not a position. So while the mandate stands, the honest way to fund a universal emergency guarantee is to fund it, openly and directly, rather than to compel it, decline to pay for it, and then finance it by cross-subsidy while cutting payment for the services that do generate revenue. I would not want that mistaken for what I actually believe. It is a second-best arrangement, recommended only because it is better than the one we have, which is to conscript the labor and then describe the resulting shortage as a failure of the market.

The second is that a great deal of what fills emergency departments is not emergency care. It is care that would have been delivered elsewhere had elsewhere been available, affordable, and open. A functioning outpatient market drains volume from the emergency department that never belonged there, which is the only intervention that addresses crowding at its source rather than at its symptom.

Even this must be qualified, and I would rather qualify it myself than have it done for me. The Oregon Health Insurance Experiment, the closest thing health policy has to a randomized trial of coverage, found that extending Medicaid coverage increased emergency department use by about 40 percent, including for conditions treatable in a primary care setting.31 That result cuts against the intuition that better outpatient access necessarily reduces emergency volume, and anyone arguing as I have just argued owes the finding an acknowledgment rather than a footnote in small type. What Oregon tested was insurance coverage in a system with constrained primary care supply, not a market in which supply could expand in response to demand, and I think that distinction matters. But it is a distinction I am offering, not a finding I can cite.

The comment period on this rule closes on September 14, 2026, and comments should be filed.32 Emergency physicians and their societies in particular should address the extension question directly, because the record on that solicitation is what a future administration will point to when it decides whether the principle travels. The argument to make is not that emergency physicians deserve more, though they do. It is that the rationale offered for the reduction is factually inapplicable to a setting where the physician has no power to schedule, and that applying it there would penalize compliance with a federal mandate.

But no one should mistake the exercise for a remedy. Physicians filed comments in 2015 and in 2019 and in every year since, many of them careful, some of them persuasive, and the line has moved inexorably in one direction regardless. The comment period is the mechanism by which a regulated profession is permitted to explain, at length and on the record, why the price it has been assigned is wrong, before receiving it anyway. It is what happens when the only available response to an unacceptable price is an essay. A professional in any other line of work who found the terms unworkable would decline them, and the decision to decline would itself be information, transmitted instantly and impossible to ignore. The emergency physician cannot decline. He is required by law to provide the service, forbidden by law to negotiate its price, and invited by regulation to submit his objections in writing by the fourteenth of September. Whatever that arrangement is, it is not modern.

I have argued here for a narrow repeal, and I would take it gladly. But I will not pretend it is what the situation calls for. Every year the profession asks for a better number, and every year the asking concedes the point that actually matters, which is that the number belongs to someone else to set. A physician who petitions for a fairer administered price has already agreed to be administered. Whatever relief he wins lasts until the following July, while the arrangement that produced the problem is left standing and is treated by everyone involved as permanent. That treatment is the only reason it has survived twenty-five years of evidence against it.

What is worth demanding is not a larger fraction of a price that someone else computed. It is the ordinary liberty every other trade in this country takes for granted: to name a price, to hear it refused, and to learn from the refusal what the work is worth. Until a physician may decline to sell at the offered rate and a patient may pay him anyway, the schedule will arrive each July with a different number in it and the same instruction attached, and we will go on writing in to explain, courteously and at length and by the deadline, why this year’s number is wrong.

This was a real child. Her account appears, under the name Chloe, among the survivor testimonies gathered by the independent Rape Gang Inquiry that the Member of Parliament Rupert Lowe released on the sixteenth of June.1 She told the inquiry that she was taken to hospital because her genitals had been split open by a glass bottle wielded by one of her many rapists, that the staff treated the injury, and that no one asked how a girl of twelve had come to suffer it.2 They repaired what was in front of them and discharged her, back to the men who had done it. On the narrowest terms, the encounter was a straightforward clinical success. The laceration was closed and the patient went home. Nothing was noticed, because noticing would have led somewhere no one in that building or in the larger British government wished to go.

I begin in the resuscitation bay rather than with the report itself because the report, for all its scale, finally comes down to rooms like that one, and to the particular cowardice of the people who staffed them. The document Lowe and his colleagues assembled is not a government product. It is a privately funded, non-statutory inquiry, paid for by more than twenty thousand donors, without the legal power to compel a single witness or document.3 Those limitations are real, but the limitations do not touch Chloe’s injury, or the staff who declined to wonder about it, and it is there that the British state’s failure becomes something a physician cannot read at a professional distance.

Consider first the question of scale, where the report is at its most vulnerable and where its critics have concentrated their fire. The figure now circulating in headlines, a quarter of a million victims, does not originate in any official count. It descends from a 2019 remark in the House of Lords, itself an extrapolation outward from the confirmed Rotherham total, and the report adopts it while conceding, to its credit, that it “is not a precise count” and that “no such count exists because the British state has failed to record it.”4 Full Fact and other reviewers have rightly cautioned that no reliable national total has ever been established.5 A reader who wishes to dismiss the entire affair will reach for that number first, but I do not need it. The figures that are firmly established are sufficient to the point and beyond it. Professor Alexis Jay’s 2014 inquiry concluded that at least fourteen hundred children were sexually abused in Rotherham alone.6 A later inquiry estimated that more than a thousand children were abused in Telford.7 The National Crime Agency’s Operation Stovewood, its investigation into Rotherham, identified around eleven hundred and fifty victims and made more than two hundred arrests across a single nine-year inquiry.8

The qualitative testimony renders the exact arithmetic beside the point. One survivor in the Lowe inquiry, called Michelle, described being raped by between six and seven hundred men over three years and becoming pregnant four times as a child.9 Whether the national figure is a quarter million or a tenth of that, the honest position is that we do not know, but the not-knowing is itself a finding. A state that declined for decades to count is a state that declined to look.

Why did no one look? The most common answer, the one that has hardened into a slogan, is that the authorities feared being called racist. Jay found that staff described their nervousness about identifying the ethnic origins of the perpetrators for fear of being thought racist, and that some recalled being given clear directions not to do so.10 The Independent Office for Police Conduct found that South Yorkshire officers had ignored the abuse out of concern for racial tensions, and a victim’s father was reportedly told by an officer that the town “would erupt” if it became known that Pakistani men were abusing white girls.11 The Telford inquiry identified a comparable “nervousness about race.”12 The early voices who tried to raise the matter, among them the Labour Member of Parliament Ann Cryer, the former detective Maggie Oliver, and the journalist Andrew Norfolk, were for years dismissed as bigots or alarmists for their trouble.13

In truth, the failure is attributable to a convergence of causes, of which the fear of racial accusation was only one. According to Jay, there was also the contempt of professionals for working-class girls, many of them wards of the state, who were treated not as victims but as wayward authors of their own degradation. There was the institutional reflex to protect the reputation of the council and the force. And there was the ordinary squalor of under-resourcing and incompetence.15 Each of these is a different vice, but every one of them is a form of an institution preferring its own comfort to the welfare of the children it existed to serve. The fear of being called racist was not a moral failing peculiar to questions of race but rather was a specific expression of a general law: that once large enough, a bureaucracy exists primarily to serve itself, and thus will protect itself before it protects anyone else.

An institution that cannot bring itself to name a pattern cannot act on the pattern. The naming is the precondition of the acting. A safeguarding apparatus that had flagged a recurring profile of offender and victim, and pursued it without sentiment, would have saved a great many children. The apparatus could not do so, not because the facts were hidden, but because the facts were unspeakable, and they were unspeakable because speaking them carried a personal and institutional cost that the people in charge declined to bear. This is the hinge of the entire affair. The abuse was enabled less by ignorance or incompetence than by a learned, rewarded silence.

When I first read of the scandal, I arrogantly believed that it could not happen in the US, because here we mandate reporting. A physician in any of the fifty states who treats a child with Chloe’s injury is required by law to report it, and is shielded from liability for doing so in good faith. It is true that the United States has built an elaborate legal architecture of mandatory reporting where Britain, until very recently, had none. But the British catastrophe was not, in the main, a catastrophe of missing rules. The authorities frequently knew. The police had names; the council had reports; the case files existed.16 What was absent was not information and not a statute but the will to act on what was already known.

I then realized that mandatory reporting is a procedure, which is precisely the thing that a self-protecting institution performs most fluently while evading the substance beneath it. Bureaucracies are great at procedure, because procedure is, by its very algorithmic nature, totally empty. Procedure stops its performer from thinking and instead sets them about following. A box can be checked by a clinician who has decided, at some level he may never admit to himself, not to see. I have argued many times before that our own system rewards documentation over outcomes, the recorded gesture over the cured patient. A reporting requirement is only as good as the courage of the person holding the pen and of those who read the report.

The machinery that produced the British silence, an institution optimizing for reputational safety, a profession in which a certain question had been rendered unaskable by the social cost of asking it, is not a foreign machinery. It operates in American medicine now, albeit pointed at a different third rail: gender medicine.

The clearest evidence is the Cass Review, the independent examination led by Dr. Hilary Cass, a former president of the Royal College of Paediatrics and Child Health. After four years and eight commissioned systematic reviews, Cass concluded that the scientific evidence for gender transition of minors was “remarkably weak.”17 More to my point, she described a clinical culture deformed by fear. The toxicity of the debate, she wrote, had made some clinicians “afraid to openly discuss their views,” and the views were voiced so aggressively that “many people are afraid to express an opinion,” a situation she called dangerous for doctors and patients alike.18 An American clinician who had worked inside the field told a reporter that the profession had “spiraled into an inability to critically think,” with so much fear among providers that ordinary clinical caution had become unspeakable.19

The symmetry is exact. In Rotherham, the clinician who suspected the truth learned that voicing the suspicion would mark him as a racist, and so he repaired the laceration and said nothing. In the American gender clinic, by the testimony of the field’s own reviewers, the clinician who counseled caution learned that voicing it would mark him as a bigot of a different name, and so he affirmed and said nothing. The specific accusation differs but the mechanism is identical. A field had attached a moral stigma to a clinical doubt, and a profession that cannot harbor doubt has surrendered the capacity for self-correction that is the only thing separating medicine from faith.

The obvious objection is that I have set a single review against the considered judgment of the profession. Every major American medical body, among them the American Academy of Pediatrics, the Endocrine Society, and the American Medical Association, continues to endorse medical transition for minors as safe and effective, and each has opposed the state bans as a political intrusion into the practice of medicine.21

My answer is that the posture of these organizations is not evidence against my argument but an example of it. They are not small partnerships of physicians answerable to the patients before them. They are large bureaucracies, subject to exactly the institutional incentives I have been describing, with the social pressure running in a single direction. Consider the body whose standards the others adopted. The World Professional Association for Transgender Health (WPATH) commissioned systematic reviews of the evidence from a team at Johns Hopkins, then published only three of the more than a dozen it had ordered. WPATH withheld the rest, whose findings proved inconvenient, while asserting in its own guidelines that such a review was not even possible.22 When minimum age restrictions for gender transition surgery were proposed, President Biden’s Assistant Secretary for Health Rachel Levine (formerly Richard Leland Levine) pressed for those age restrictions to be removed, on the stated worry that they would invite restrictive legislation, and removed they were.23 This is not the conduct of an institution weighing evidence. It is the conduct of an institution managing a political liability, which is the same conduct that discharged a twelve-year-old without a question. That the European authorities in Britain and Sweden and Finland who examined the very same literature moved instead toward caution only sharpens the point.24 An organization more frightened of accusation than of inflicting injury will reliably produce the consensus the accusation demands, and will call the result science.

It would be a mistake, and a betrayal of the principle I am defending, to imagine that the remedy is for the state to march in and impose the opposite orthodoxy by force. That is, in large part, what has now happened. In United States v. Skrmetti the Supreme Court upheld Tennessee’s ban on this care for minors, and roughly two dozen states now prohibit it, several under criminal penalty.25 Though I oppose gender transition, I take little comfort in that. A legislature that forbids a course of treatment by statute has not restored clinical judgment; it has replaced one external compulsion with another, and a physician forbidden by the state to weigh the evidence is no freer than one forbidden by his peers to question it. When I speak of liberty, I do not mean that the government has the liberty to dictate the answer. I want the freedom of the individual physician to weigh the evidence for himself and to follow it wherever it leads, and the duty, inseparable from that freedom, to hold his judgment answerable to the patient alone.

The failures I have described are not failures of too little regulation. England certainly does not lack rules and will not be cured by more of them. The problem is that the bureaucracy is the one human institution engineered specifically to escape consequence, to diffuse responsibility until no single hand can be found on any single failure. A system so engineered will reliably choose its own reputation over a child on a gurney, because nothing in its design makes the child’s fate its own. A market disciplines through exposure to loss; the spontaneous order that freely arises from it disperses authority precisely so that no single edifice can declare an entire category of suffering to be unspeakable. That is not a promise that evil will not occur, but it is a refusal to hand any institution the power and incentive to look away at scale.

The physician’s loyalty is supposed to be owed only to the person in front of him. Not to the trust that employs him, not to the council that would prefer the matter quiet, not to the prevailing sentiment of his profession or the temper of his age. A clinician who understood that would have looked at a twelve-year-old with genital lacerations and thought about something more than which suture material to use. He did not, and the reason is the quiet curriculum of every institution grown large enough to fear for itself, which teaches that the first duty is not to do no harm but to notice no harm, and to leave the unthinkable unthought. The injury told him everything. What his training had not given him, and what no protocol can issue, was the nerve to ask the next question and to act on the answer. That is the failure beneath all the others, in an English emergency room and in the American clinics now quarreling over what a doctor is permitted to doubt. An institution can compel a clinician to file a report. It cannot legislate the courage to act on what the report would have to say.

If the phrase is going to enter the language, we may as well coin it properly. What Midjourney describes is computed tomosonography, a cross-sectional picture of the body built not from X-rays but from echoes. The hardware is real enough; the ultrasound modules are licensed from an established firm, Butterfly Network, which felt obliged to issue its own statement clarifying its role after the announcement made the technology sound like a fever dream of generative software.2 But Midjourney Medical does not yet exist as a product anyone can buy. It has no regulatory clearance, no peer-reviewed validation, and a flagship location penciled in for late 2027. It is a prototype and a press release. What it makes vivid, though, is a phenomenon that is already here, already taking your money, and already generating litigation.

That phenomenon is the elective whole-body scan sold to people who feel perfectly well. Its most prominent vendor is Prenuvo, which offers a radiation-free whole-body MRI read by affiliated radiologists and marketed as capable of detecting “500+ conditions across 33 organs.” Memberships run from roughly twelve hundred dollars a year to several thousand, the company has performed well over a hundred thousand scans, and it enjoys the kind of celebrity endorsement that money can buy, including a famous social-media post calling the machine “lifesaving.”3 Prenuvo’s strongest piece of evidence, a study it calls Polaris, reports that among about a thousand mostly asymptomatic adults, 2.2 percent were found to have a cancer confirmed by biopsy. It is worth knowing that Polaris has been presented only as a conference abstract, not published in a peer-reviewed journal, that it was conducted at a single site without a control group, and that it measures detection rather than benefit. It reports no effect on how long anyone lived.4

Here the public divides into two camps that regard each other with mutual incomprehension. On one side stand the technologists and much of the lay public, who hold a simple and intuitive conviction: more information about your body can only help you. They marshal stories, and the stories are genuinely moving, of the friend whose tumor was caught early on a scan done for some unrelated reason, the colleague who would be dead but for an incidental finding. On the other side stand most physicians, who hold a proposition that sounds, to the first camp, almost perverse: that bad data can be worse than no data at all. The doctors worry about incidental findings, the ambiguous shadows and indeterminate nodules that lead to biopsies, to surgeries, to a cascade of investigation that carries its own real harms. The two sides are not weighing the same things. One counts the lives a scan might catch. The other counts the harms a scan reliably causes. And anecdote, by its nature, only ever reaches the first ledger.

I will confess that my own sympathies are not entirely where my white coat would put them. I am excited by this technology. The vision the enthusiasts describe, a machine that can look inside a living body and reliably sort what matters from what does not, is a thing I want to exist, and I believe the only road to it runs through exactly the kind of restless private invention these companies embody. Nothing that follows is an argument that we should not build such a device, or that the dream is foolish. It is a very good dream. But the dream is not what is being sold. What Prenuvo sells today, and what Midjourney proposes to sell tomorrow, is at best the same MRI a clinician would order for a patient with an actual complaint, and often something less capable. The picture is no better than what medicine already has. By the one measure that matters it is worse, because it arrives stripped of the clinical question that gives any image its meaning. The enthusiast imagines he is buying an early glimpse of the perfected scanner. He is buying an ordinary scanner used in the single circumstance guaranteed to degrade what it can tell him. These companies trade on the credibility of a future product to move a present one that is, by that measure, a step backward.

I want to be honest about how hard this is, because the hardest case I know is my own family. My mother, who is herself a physician, had a renal cell carcinoma found incidentally on a CT scan ordered for an attack of diverticulitis. The tumor was about a centimeter across. For a solid renal mass that small, the guidelines do not tell you to operate. They tell you to watch it, because a tumor under four centimeters rarely behaves aggressively, and because the risks of surgery, the bleeding, the loss of kidney function, the operative complications, generally outweigh the benefit of removing something that was very unlikely ever to harm you.5 The evidence here is not soft. A decade of prospective data on small renal masses shows no meaningful difference in cancer-specific survival between the patients who had surgery and the patients who were simply observed.6 My mother knew all of this. She had the tumor removed anyway, largely at her own insistence, because she could not abide the thought of a cancer sitting inside her, and she knew she would never relax again if she chose to do nothing. As her son, I find it almost impossible to argue with her. As a physician trying to be dispassionate, I have to admit that what she chose was, by the evidence, the wrong call.

That contradiction is the whole matter in miniature. A trained doctor, presented with her own data, did not behave as a calm Bayesian weighing risks and benefits. She behaved as a person who had just learned she had cancer. And if a physician cannot reliably hold that line, it is fantasy to imagine that the technology executive, or the worried-well thirty-something with disposable income, will hold it either. This is the fact the enthusiasts keep stepping around. The problem with an incidental finding is not only that it is often a false alarm. The problem is that once you know about it, you cannot un-know it, and the doing-nothing that the evidence recommends becomes, for almost everyone, psychologically unavailable. The scan does not just give you information. It gives you a burden you did not have to carry, and then it sells you the surgery to put it down.

Why should bad data be worse than none? The answer is a matter of arithmetic that every clinician understands and most patients are never taught. The usefulness of any test depends on how likely the disease was before you tested. Run a scan on a population riddled with a disease and even an imperfect test is informative. Run the same scan on a crowd of well people, where almost no one has the thing you are hunting, and the math inverts: most of the alarms it raises will be false, and a great many of the rest will be findings that were never going to matter. This is not a hypothetical worry. A systematic review of whole-body MRI in asymptomatic people found a pooled false-positive rate around one in six, with indeterminate or critical incidental findings common and no study able to demonstrate that any of it prolonged a life.7 Prenuvo itself reports that roughly half the people it scans walk away with something to keep an eye on. And the consequences of all that watching are documented. In a national survey of physicians, virtually every respondent, 99 percent of them, reported having personally seen an incidental finding set off a cascade of further testing, and they described those cascades inflicting psychological harm, physical harm, and financial harm on their patients.8 The look is cheap. The looking-into is not.

If you want to know where this road ends, it has already been traveled, and the country that traveled it ran the experiment cleanly enough to publish the results. Beginning in the 1990s, South Korea added cheap thyroid ultrasound to its health screening, and physicians began finding tiny thyroid nodules in enormous numbers. By 2011 the rate of thyroid-cancer diagnosis was fifteen times what it had been in 1993. It looked like an epidemic. It was not. Thyroid-cancer mortality over the same period did not budge, the unmistakable signature of overdiagnosis, of finding cancers that were never going to kill anyone.9 What the screening did change was the number of thyroids removed. Most of those patients underwent surgery, and surgery has a price that does not appear on the brochure: in an analysis of more than fifteen thousand of them, 11 percent were left with hypoparathyroidism and 2 percent with vocal-cord paralysis, and most now depend on thyroid hormone replacement for the rest of their lives.10 Then came the part that proves the case. A group of physicians publicly urged the country to stop screening healthy people, and the country largely did. Diagnoses fell by about a third. Operations fell by more than a third. And nobody was worse off, because the cancers that vanished from the statistics were the ones that were never going to harm anyone in the first place.11 You cannot ask for a more direct demonstration. Screening asymptomatic people manufactured disease, the disease was treated with morbid surgery, and the cure was simply to stop looking.

There is a further problem, specific to imaging, that the technologists have not reckoned with, and it concerns the radiologist whose name goes on the report. A scan ordered for a reason comes with a question attached. The patient has chest pain, or a palpable mass, or an abnormal blood test, and that clinical context tells the radiologist what he is looking for and, just as importantly, what he can safely ignore. A whole-body scan on a well person arrives with no question at all. It asks the reader to evaluate everything and to privilege nothing, which is not a richer task but an impossible one, because significance is most often not a property an image has on its own. It is a judgment that depends on context the scan has deliberately stripped away. Confronted with that, and mindful of his own exposure, the careful radiologist does the only safe thing. He flags everything he possibly can. The over-calling is not incompetence but the rational response of a person who knows that the finding he dismisses is the one that will be read aloud in a courtroom.

And the courtroom is a very real consideration. A New York man who paid twenty-five hundred dollars for a Prenuvo scan in 2023, and was told his brain looked normal, suffered a catastrophic stroke some months later in that very region. His attorneys, citing a neurologist they retained, contend that the original images showed a sixty-percent narrowing of a major cerebral artery that the report failed to mention, and that it might have been treated had anyone documented it.12 The case is winding through the New York courts, and I would not pretend to know how it comes out.13 But notice the bind, because it cuts in both directions at once. The radiologist who misses something is sued, as this one was. The radiologist who over-calls everything generates the cascades we have just spent this essay cataloguing. There is no safe reading of a scan that was performed without a reason, because the absence of a reason is precisely what makes a confident read impossible. That impossibility is not a failure of the radiologist. It is the predictable product of pointing a camera at a healthy man and asking it to find his future.

It is worth being precise about which findings actually cause the trouble, because the enthusiasts are not entirely wrong about some of them. The lung nodule and the small thyroid mass, the staples of the overdiagnosis literature, are in truth the manageable case. We know how to watch a nodule. We follow it on serial images, most are never biopsied, and a device that could track such a thing cheaply and without radiation, should it ever perform as promised, would be a real convenience, whatever it did to the raw count of procedures. The heart of the problem lies elsewhere, in the finding we do not know how to act upon at all. Return to that alleged sixty-percent narrowing of a cerebral artery, and suppose it was really there. What follows from knowing it? No surgeon opens the skull to repair a moderate, nonobstructive atherosclerotic lesion in an otherwise well man. The finding does not change his treatment. It changes one thing only: it gives him, and his lawyer, someone to blame when the stroke eventually comes. And where such findings do prompt action, the action is invasive. An incidental coronary calcification can send a patient to a cardiac catheterization; a suspicious cerebral vessel can send him to catheter angiography of the brain. These are not biopsies, but they carry their own real risks. Even the gentler follow-ups are not free, because the confirmatory CT or the catheter study delivers the very radiation these scans are advertised to spare you, and the contrast that CT and MRI often require carries hazards of its own. The point bites hardest against the ultrasound spa, because sound waves penetrate the body poorly, and the vague signals such a device produces will almost always have to be chased with the more capable modalities, the CT and the MRI, that it was meant to render unnecessary. The radiation-free scan turns out to be the first step on the road to the radiation.

The enthusiasts have an answer ready for all of this, and the answer is artificial intelligence. The machines will read the scans, they say, and the machines will not tire or err or hedge. I am skeptical, and the reason follows directly from everything above. An algorithm has no more clinical context than the human radiologist does, because the context is missing from the scan itself, not from the reader. The model still has to decide what counts as a finding and what does not, still has to separate the shadow that matters from the thousand that do not, and it must make that call, as the human must, without the clinical question that would tell it which is which. Significance is contextual, and a system handed no context cannot supply it. AI does not dissolve the radiologist’s predicament. It automates it, and at the scale Midjourney imagines, a billion scans a month, it automates it across the entire population at once.

There is a second reason to doubt the machine, and it concerns not what the model can do but how it would have to learn. The tech-minded reply to everything above is scale: feed the system millions of scans and it will learn, as we did, to tell the ominous from the harmless. But a scan does not arrive labeled. The model cannot learn significance from images alone, any more than a radiologist could, because significance is established only by what the workup eventually proves. The label on the training image is the biopsy result, the surgical pathology, the catheter that confirmed or refuted the lesion. To teach the algorithm what matters, in other words, hundreds of thousands of people must first undergo the invasive workup that produces the answer. The training data is human morbidity. Perhaps that bargain is even worth striking, in the long run. But it is a fair one only if the people being scanned understand that they are not merely customers. They are the training set, and the tuition is paid in their own biopsies.

Some online defenders wave all of this away with a single move: if the incidental findings are so troublesome, just ignore them. The suggestion barely survives contact with how medicine works. A physician cannot be shown a finding and then unsee it, and a patient cannot be told there is a shadow on his scan and then be expected to forget it. The law will not permit the pretense from either of them. We have spent this entire essay on the fact that knowledge, once acquired, cannot be set down at will. “Just ignore it” is not a policy. It is a wish.

So what should a free society do about a product that healthy people want to buy and that the evidence says will mostly harm them? The libertarian reflex, and I share its starting point, is to say it is my body and my money and my business. Liberty is the governing principle, and I do not reach for prohibition lightly. But look closely at what is actually happening here, because it is not a free market functioning. It is a market failure wearing the costume of consumer choice. Two distortions give the game away. The first is that the buyer does not bear the true cost of his purchase. The scan is paid out of pocket, but the cascade it sets off, the confirmatory MRI, the biopsy, the specialist referral, the operation, is billed to insurance and spread across everyone in the risk pool. The purchaser keeps the reassurance and the novelty. The rest of us get the invoice. That is the textbook definition of an externality, and a market in which the buyer captures the benefit while strangers absorb the cost will always produce too much of the thing. The second distortion is that the liability lands on the wrong people entirely. The radiologist who never wanted to read an unindicated scan carries the malpractice exposure, and so does the internist downstream who did not order the thing and must now chase its incidentalomas to ground. The company that marketed the scan to a well man, that built the spa and ran the advertisement and took the fee, walks between the raindrops.

The remedy is not the prohibitionist instinct, the impulse to forbid the product outright and treat grown adults as wards of the state. The remedy is to make the market honest, which means making the prices and the liabilities tell the truth. Let people buy the scan. But let the seller bear what the scan sets in motion. If a company sells you a look, that company should own the workup the look generates, or insure against it, so that the downstream cost is priced into the ticket rather than mailed to the insurance pool. Aim the tort liability at the party that created the risk and profited from it, the marketer who solicited a healthy customer, rather than at the contracted radiologist or the treating physician left holding the bag. And require the same honest disclosure at the point of sale that we would demand of anyone else making a health claim: the false-positive rate, the rate of incidental findings, and the plain fact that no whole-body scan of asymptomatic people has ever been shown to make them live longer.14 This is what tort reform should mean in this context. Not a shield for the companies selling the scans, but liability aimed correctly, at the people who sell them.

What we have instead is the worst of both arrangements, the aesthetics of a free market joined to the economics of a subsidized one. A company forced to price in the strokes it fails to predict and the thyroids it needlessly removes would have to ask whether its product survives at its true cost, and many of these scans would not survive the question. That is not a verdict against the future. I began by confessing that I want the machine the enthusiasts describe, and I meant it. The day will likely come when a device can look inside a well person and tell him, reliably, what is worth his worry and what is not, and that day will be an advance worth celebrating. But it arrives through honest validation, honest prices, and an honest assignment of who answers for the consequences, not through a spa that sells a worse scan today on the credit of a better one promised for tomorrow. My mother’s choice should stay with us here, because it was not irrational and it was not ignorant. It was human. Once a person knows there is a cancer inside him, he will rarely choose to do nothing, and no amount of counseling reliably changes that. It is the permanent condition of being mortal and aware of it. Which is exactly why the looking should not be sold casually, as an amenity beside the cold plunge, to people who arrived with no question to answer and no way to bear the answer they are given. The honest price of a look includes everything that follows from it. Sell it that way, to people whose eyes are open, and you have a market and perhaps, in time, a genuine advance in medicine. Sell it as it is sold now, and you have a sales pitch, with the bill addressed to the rest of us.

The medical establishment and advocacy community have largely greeted this trend with alarm and a call for more resources. Secretary of Health and Human Services Robert F. Kennedy Jr. declared an “autism epidemic.” Most researchers point to improved awareness, earlier screening, and expanded diagnostic criteria as the primary drivers of the increase. A minority argue that something environmental is genuinely making more children autistic. I want to make a different case: that the explosion in autism diagnoses is substantially the product of a progressive loosening of diagnostic standards, that this loosening has been encouraged and accelerated by a web of financial incentives operating at every level of the system, and that the consequences of this diagnostic inflation are serious for patients, for physicians, and for honest public discourse about children’s health.

Let me be clear about what I am not arguing. Severe autism is real, it is devastating, and the families who live with it deserve every support society can offer. I am not claiming that autism does not exist, that it has not increased at all, or that all children carrying the diagnosis are merely misbehaved. I am arguing that the diagnostic category has been stretched well past the point of clinical coherence, and that this stretching has been driven in no small part by forces that have little to do with medicine.

To understand how we arrived here, one must trace the evolution of the diagnostic criteria themselves. When the American Psychiatric Association published the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980, autism was defined narrowly and severely: “lack of interest in people,” “severe impairments in communication,” and “bizarre responses to the environment.”3 This language described a profoundly impaired child. The diagnosis was rare because the condition it described was genuinely rare. The fourth edition, published in 1994, broadened the criteria substantially. “Severe impairments” became “qualitative impairments.” The concept of a spectrum was introduced, bringing in milder presentations including Asperger’s syndrome. Children who could communicate, who formed attachments, and who functioned at or near grade level could now qualify if they exhibited certain patterns of restricted interest or social awkwardness.4 The fifth edition, published in 2013, consolidated all subcategories into a single unified Autism Spectrum Disorder diagnosis and formally defined three severity levels. Level 3 corresponds roughly to what most people understood autism to mean historically: profound impairment requiring very substantial support. Level 1 requires only “support” for difficulties in social communication and flexible behavior. A child who becomes intensely absorbed in a narrow topic, who struggles with unstructured social situations, or who resists unexpected changes to routine can now qualify for a Level 1 diagnosis.5 The diagnostic language has shifted from concrete and observable to subjective and dimensional.

I speak with some personal authority on what a Level 1 diagnosis would have looked like in practice a generation ago. Growing up in the 1990s, I was a “geeky” kid with obsessive interests and hobbies, with hours spent on niche projects or memorizing obscure details. Making friends and fitting in didn’t come as naturally to me as it did to my peers. Fortunately, my schoolteachers saw these traits not as problems but as hallmarks of a “gifted” child. They placed me in a gifted program, where I met other intelligent, nerdy kids with their own unusual passions. Together, we thrived, achieving remarkable feats like winning international web design competitions and the National School Scrabble Tournament. I can’t help but suspect that had I been born just 25 or 30 years later, the same characteristics might have landed me a diagnosis of Level 1 autism instead of a spot in a gifted program. Rather than celebrating my strengths, today’s system might have placed me in special education. How differently would my life have gone, had that been the case? I doubt I would be a physician today. What’s more, how much damage would have been done to my developing psyche to be explicitly told that not only did my classmates think I was a little weird, but that all the adults thought so too -- so much so that they considered me to have a disease?

Autism is not the only psychiatric diagnosis that has undergone this kind of expansion. Attention Deficit Hyperactivity Disorder affected roughly 7.8 percent of American children in 2003; by 2022, that figure had risen to 11.4 percent.6 Pediatric bipolar disorder, nearly unrecognized before the 1990s, is now diagnosed in 1 to 2 percent of children.7 Anxiety disorders, once estimated to affect approximately 5 percent of children, now appear in surveys at rates exceeding 30 percent.8 Oppositional Defiant Disorder deserves particular scrutiny. The DSM-5 criteria for this diagnosis include “often loses temper,” “is often touchy or easily annoyed,” “often argues with adults,” and “often blames others for his mistakes.”9 These criteria must persist for at least six months and occur in the context of at least one relationship outside the sibling relationship. I would ask any parent of an adolescent whether they recognize this description. The fact that it constitutes a diagnosable psychiatric disorder is, at minimum, a serious question about where we have drawn the line between illness and ordinary human difficulty. The cumulative picture across these diagnoses is not one of a population growing sicker. It is one of a diagnostic enterprise that has progressively pathologized a wider range of human temperament, behavior, and development. The explanation that awareness has simply improved does not account for the magnitude and consistency of these increases across conditions, across age groups, and across nations.

There is a dimension of this problem that the medical literature rarely addresses directly: the question of who benefits financially from a diagnosis of autism, and how those incentives shape behavior at every level of the system. For families, particularly those in lower-income brackets, an autism diagnosis for a child unlocks a significant portfolio of public benefits. Through the Supplemental Security Income program, a qualifying child can provide the household with monthly federal payments; the current federal benefit rate is $994 per month for an individual.10 A diagnosis also typically establishes eligibility for Medicaid, which covers applied behavior analysis therapy, occupational therapy, speech therapy, and related services. Many states offer Medicaid waiver programs that expand eligibility beyond standard income limits and fund in-home support services. The Individuals with Disabilities Education Act guarantees a free and appropriate public education in the least restrictive environment, which in practice often means an Individualized Education Plan, supplemental aide services, and modified academic expectations.11 Autism diagnoses also qualify children for ABLE accounts, tax-advantaged savings vehicles, and for a range of state-specific grants and respite care programs.12 These programs exist to serve children with genuine and serious needs, but they create a powerful and largely unacknowledged incentive structure. When a diagnosis of autism transforms a child’s relationship to state and federal welfare systems, the decision to seek and accept that diagnosis is no longer a purely medical one.

I observe the downstream effects of this incentive structure daily in my practice as an emergency physician. Children arrive in the emergency department in behavioral crisis, and a review of their records reveals a constellation of psychiatric diagnoses accumulated over years: autism, ADHD, anxiety disorder, oppositional defiant disorder. What strikes me is not the presence of these labels but their apparent insufficiency as explanations. These children are often in genuine distress, but the distress frequently appears to track circumstances rather than neurology: a change in custody, an eviction, a parent’s absence, a household in chronic dysfunction. The psychiatric vocabulary has been applied to what looks, in the clinical encounter, more like a social crisis than a medical one. This observation is admittedly anecdotal, and I am cautious about drawing firm conclusions from emergency department presentations, which are by definition a selected and unrepresentative sample of children with these diagnoses. But it raises a question that the literature engages only reluctantly: to what extent does the diagnosis serve the child’s medical needs, and to what extent does it serve as the mechanism by which a family in distress gains access to services it would not otherwise receive? When the diagnosis is the key that unlocks a portfolio of benefits, families have every rational reason to seek it and clinicians have every professional reason to provide it. The child, in this transaction, functions less as a patient and more as a credential.

The incentives do not stop at the family level. School districts receive funding through IDEA that is tied to the number of students identified as having disabilities. Prior to 1999, federal IDEA grants were calculated directly from the count of students with disabilities, a formula that Congress itself recognized as creating incentives for over-identification and subsequently revised.13 The basic dynamic remains: more diagnosed students can mean more resources flowing to a district. For providers in states with generous Medicaid reimbursement for autism services, the financial incentives are more explicit still. Applied behavior analysis therapy is reimbursed at substantial rates, and the proliferation of autism treatment centers, assessment clinics, and early intervention providers represents a genuinely profitable industry that is entirely dependent on the continued supply of autism diagnoses.

The most dramatic illustration of how these incentives can metastasize involves the state of Minnesota, which has seen what federal prosecutors have described as a web of interlocking Medicaid fraud schemes amounting to, by some estimates, billions of dollars in fraudulent claims across multiple state programs.14 The autism component of this scandal centers on Minnesota’s Early Intensive Developmental and Behavioral Intervention program, which provides Medicaid-funded therapy to children diagnosed with autism spectrum disorder. Federal prosecutors charged the first defendant in this investigation in September 2025: Asha Farhan Hassan, who operated a clinic called Smart Therapy and was charged with wire fraud for her role in a $14 million scheme. According to the Department of Justice, Hassan and her partners actively recruited children from the Somali community to enroll in Smart Therapy, and when a recruited child did not already carry an autism diagnosis, they worked with a qualifying service professional to ensure the child obtained one. Court documents state that there was no child that Smart Therapy was not able to get qualified for autism services.15 Parents who enrolled their children received monthly cash kickbacks ranging from $300 to $1,500 per child. Smart Therapy’s employees included 18- and 19-year-olds with no relevant training or education.16

Hassan’s case was described by Acting United States Attorney Joseph H. Thompson as “not an isolated scheme.”17 The number of autism therapy providers in Minnesota grew from 41 in 2018 to 328 in 2024, a 700 percent increase. State payments for autism claims went from roughly $6 million in 2018 to nearly $192 million in 2024, and prosecutors believe the majority of that increase represents fraudulent billing.¹¹ A second defendant, the owner of a clinic called Star Autism Center, subsequently pleaded guilty to a parallel scheme.18 Of the 92 individuals charged across the various Minnesota fraud schemes as of late 2025, 82 are Somali American, a fact that has attracted considerable political attention.19

I do not think that the ethnic composition of the defendants is evidence of a cultural predisposition toward fraud. Rather, I believe it is a predictable consequence of exploiting social networks within a concentrated immigrant community. Fraud organizers approached parents in the Somali community because that community was large, concentrated in the Twin Cities, and already familiar with a social services infrastructure on which many members depended. The state’s own auditors have acknowledged that fear of being accused of racial discrimination made regulators reluctant to investigate complaints, allowing the fraud to grow for years before serious prosecution began.20 What the Minnesota scandal illustrates is not particular to the Somali community. It is a predictable consequence of a system in which the people disbursing money have no personal stake in whether it is spent honestly. A private insurer or charity must earn its revenue and answer to those who fund it; a government agency disburses tax dollars collected by compulsion and bears no meaningful cost when those dollars are stolen. The invitation to fraud was built into the program's architecture from the beginning, and it was accepted with enthusiasm. It was made orders of magnitude worse by a system which attached enormous financial rewards to a diagnosis that is inherently subjective and impossible to verify objectively.

That last point deserves emphasis. Autism spectrum disorder, particularly at Level 1 severity, has no biomarker, no blood test, no imaging finding. The diagnosis rests entirely on behavioral observation, clinical judgment, and parental report. This is not a criticism of clinicians who make the diagnosis honestly and carefully. It is an observation about the vulnerability of a subjective diagnostic standard to systematic abuse when significant sums of money are in play, and about the impossibility of auditing claims in any meaningful way when the underlying condition is defined behaviorally.

When the word “autism” described a child who was nonverbal, unable to form relationships, and incapable of independent living, it carried a weight that commanded a particular kind of social and institutional attention. When the same word describes a highly verbal, gainfully employed adult who identifies as autistic because he has narrow interests and finds small talk effortful, that weight is diminished. And when it is diminished, something else is lost as well: the urgency that attaches to serving people with severe and genuine impairments. The recent controversy over RFK Jr.’s characterization of autism as a severe disability prompted significant backlash from people who insisted their children, or they themselves, are “perfectly functional.” Some went further, arguing that autism is not a disease at all but a form of neurodiversity analogous to other dimensions of human variation. Whatever the philosophical merits of that position applied to high-functioning individuals, it would be strange indeed to apply it to a child who cannot speak, cannot dress himself, and cannot be left unsupervised. Both populations currently share a diagnostic label. That is a problem of taxonomy with real clinical and policy consequences.

Intellectual honesty requires engaging seriously with the most significant counterargument to the overdiagnosis thesis. The HHS press release accompanying the April 2025 CDC report noted that the proportion of children diagnosed with autism who have above-average IQ scores has decreased steadily over the past several reporting cycles, with nearly two-thirds of children in the 2022 survey classified as having at least borderline intellectual disability.21 If the rise in prevalence were driven purely by the addition of high-functioning, mildly affected individuals to the diagnostic category, one would expect the opposite trend. The counterargument, in its strongest form, is that we are finding genuinely disabled children who were previously missed.

This argument deserves a direct answer rather than a concession, because the intellectual disability data is considerably less straightforward than it appears. The most important factor is reclassification. Under the DSM-III and DSM-IV, autism and mental retardation were separate diagnoses assigned on separate diagnostic axes. A profoundly impaired child with low IQ and social deficits would typically receive a primary diagnosis of mental retardation, with autism either noted secondarily or not at all. Research published in the Journal of Medical Genetics found that 69 percent of individuals diagnosed with intellectual disability under prior criteria are likely to be recategorized and diagnosed with autism under current standards.22 The DSM-5 eliminated the multiaxial system entirely, making intellectual disability a co-occurring condition that sits alongside an autism diagnosis rather than competing with it. What this means in practice is that a substantial portion of today’s autism-plus-intellectual-disability population is almost certainly yesterday’s mental retardation population, carrying a new label without representing any new underlying pathology. The children did not change. The filing system did.

This interpretation is further supported by the historical trend in the comorbidity rate itself. In the 1980s, approximately 69 percent of individuals diagnosed with autism also carried a diagnosis of intellectual disability. By the mid-2010s, that figure had fallen to roughly 30 percent nationally, even as the raw number of autism diagnoses surged.23 The new cases being added to the autism rolls were overwhelmingly the milder, higher-functioning ones. The recent uptick in the intellectual disability comorbidity rate does not reverse this long-term trend so much as partially reflect the exhaustion of the high-functioning pool and the systematic incorporation of previously labeled intellectually disabled children into the autism category.

The Minnesota data on the Somali population adds a further complication that the counterargument cannot easily absorb. A 2025 University of Minnesota study found that 1 in 12 eight-year-old Somali children in the Twin Cities metro area carried an autism diagnosis, compared to 1 in 28 for the overall Minnesota population. Among Somali children with autism who had IQ test results in their records, 65 percent had intellectual disability, a rate substantially higher than the 37 percent observed in the overall Minnesota autism population.24 At first glance this appears to support the genuine-severity hypothesis. But 46 percent of Somali children with autism had no IQ test results in their records at all, leaving the true rate unknown. More importantly, this is precisely the population at the center of the Minnesota Medicaid fraud investigation, in which providers were recruiting Somali children indiscriminately, obtaining autism diagnoses for children who did not have them, and billing Medicaid for services that were never rendered. When fraud is the mechanism generating diagnoses in a specific community, the resulting prevalence data for that community cannot be taken at face value. The elevated intellectual disability rate among Somali children may reflect a genuine biological phenomenon, an artifact of language barriers and culturally inappropriate assessment instruments, the downstream effect of consanguineous marriage practices on neurodevelopmental outcomes, or simply the consequence of fraudulent diagnoses being assigned disproportionately to children who were already known to the system for other developmental concerns. The researchers themselves describe the finding as important and unexplained. It cannot do the work the counterargument would require it to do.

Some readers will note that population-level IQ data for Somalia have been cited in certain quarters as a partial explanation for the elevated intellectual disability rates among Somali children with autism in Minnesota; the evidence underlying those figures is methodologically thin, heavily disputed in the peer-reviewed literature, and in any case confounded by the profound effects of war, famine, educational deprivation, and the documented cognitive consequences of vitamin D deficiency during pregnancy in a population that relocated from an equatorial climate to the upper Midwest.

The honest summary is this: the rise in autism diagnoses among children with intellectual disability is substantially explained by the reclassification of children who were previously diagnosed with mental retardation under an older diagnostic framework. The remaining increase reflects a genuine mix of improved identification of severely affected children who were historically overlooked, diagnostic expansion into populations previously served under different labels, and in some communities, outright fraud. None of this requires us to conclude that the underlying prevalence of severe, biologically grounded autism has increased at anything approaching the rate the raw numbers suggest.

The physician who diagnoses a child with autism in the current system faces almost no professional cost for doing so and potentially avoids significant friction. A diagnosis can be documented quickly, it satisfies the family’s desire for an explanation, it connects the child to services, and it insulates the clinician from criticism that he failed to identify a condition. Declining to diagnose, or recommending watchful waiting, requires time, sustained explanation, and tolerance for uncertainty. The incentive structure runs entirely in one direction. A health care system organized on genuine free market principles would introduce countervailing pressures. When private insurers bear the cost of services associated with a diagnosis, they have a direct financial interest in ensuring that diagnoses are applied accurately and that claimed services are actually rendered. When the state is the payer, as it is for the tens of millions of children enrolled in Medicaid, no such countervailing interest exists. The payer does not negotiate, does not question, and does not bear the cost of diagnostic error in the way a financially accountable private insurer would. The explosion of Minnesota’s autism provider rolls from 41 to 328 in five years would have triggered scrutiny far earlier in a system where someone stood to lose money by paying fraudulent claims, rather than a system in which the money being paid belonged to no one in particular and to everyone in general.

Children with genuine, profound autism deserve accurate diagnosis, sustained support, and serious medical attention. Children who are shy, intense, easily frustrated, or socially awkward deserve patient adults, appropriate challenge, and the benefit of the doubt that their struggles fall within the ordinary range of human variation. Conflating these two groups does not serve either one. It burdens genuinely normal children with a medicalized identity, diverts resources from those who most need them, and creates the conditions under which a $192 million fraud can grow quietly in plain sight for six years before anyone investigates. The willingness to say so plainly is not cruelty toward disabled children. It is the precondition for actually serving them.

The justification is, as always, the dollar, and more specifically, what the government requires one to do to earn it. Programs such as Merit-based Incentive Payment System reward the documentation of “complexity,” and social conditions have been folded into that accounting. The chart expands. The metrics improve. Higher payment follows. None of this improves the care delivered in the room. It does, however, reveal the conceptual framework now guiding much of modern medicine.

We are told these are “social determinants of health.” That language bothers me a great deal. The terminology was taught to me in medical school to refer to epidemiological variables that were associated with poor health outcomes, but the word “determinant” carries a misleading connotation, perhaps intentionally, although perhaps that is overly cynical. The ordinary meaning of “determinant” implies that the factor in question exerts a decisive influence, that it fixes the outcome in an inexorable way. That implication is never justified or even admitted, yet it is precisely how the term is now used in policy, documentation, and everyday clinical language.

I do not think this is a trivial semantic complaint. When a risk factor is described as a determinant, probability is equivocated with certainty, correlation masquerades as causation, and context is recast as mechanism. Most importantly, these so-called “social determinants” all reflect discrete, ongoing lifestyle choices made by human beings with agency, and yet the very term “determinant” strips away the idea of choice and replaces it with inexorable fate.

Consider what these categories actually represent. Homelessness does not, by itself, produce disease in the way that a pathogen does. It is associated with illness, often strongly, but there is no causal mechanism by which not having a home causes a disease. Camping is not considered a social determinant of health for this reason. Famed rock climber Alex Honnold spent a decade “homeless” and living out of a car at various crags and climbing locales, yet no one would consider him to be high risk for diabetic foot amputations. Why is that?

The association is entirely because “homelessness” as a social determinant functions as a proxy word, a euphemism to describe a pattern of extremely poor and unhealthy lifestyle choices. Poor nutrition, violence, criminality, mental illness, drug use, irregular care, and nonadherence all contribute, and those who we describe as “homeless” tend to behave this way. These choices are so deeply intwined in the connotation of homelessness that even though Alex Honnold was by definition homeless, no one ever described him that way, because he was at the same time athletic, healthy, famous, and rich, living at what essentially served as his gymnasium, instead of drug-addled, mentally ill and violent, harassing pedestrians on the streets of L.A.

The same is true of substance use and obesity. There are direct physiologic effects. There is also a broader constellation of choices that accompany these conditions, choices that more immediately drive outcomes. It is therefore more accurate to say that many so-called determinants function as proxies. They mark a way of living. They signal a pattern. They do not, in themselves, explain the outcome. When we attribute causation to the label, we obscure the mechanisms that matter.

This matters because people are not interchangeable units acted upon by external forces. They are agents. They act within constraints, but they act. Two individuals facing similar circumstances do not reliably arrive at the same place. Some adhere to treatment, seek care, and modify behavior despite disadvantage. Others do not. That variation is not incidental. It is central. It reflects differences in decision-making, priorities, and response to adversity. Put differently, it reflects differences in character.

The current framework does not account for this. By describing these factors as determinants, it suggests inevitability. The patient becomes the product of his environment. Outcomes are framed as the natural consequence of circumstance rather than as the result of an interaction between circumstance and choice. This is often presented as compassion. It has the opposite effect. It strips the patient of agency. It reduces a human life to a set of inputs and outputs.

When the electronic record automatically assigns these conditions as diagnoses, it encodes this worldview into the practice of medicine. The chart becomes a document not only of illness but of ideology. It asserts, before any clinical reasoning has taken place, why the patient is unwell. It does so in a way that is convenient for measurement and reimbursement, not necessarily for understanding or care.

It also directs attention away from the proximate drivers of health. If the problem is homelessness, the solution becomes housing. If the problem is food insecurity, the solution becomes access. These may be worthwhile aims. They are not sufficient explanations. They do not address the behaviors that mediate risk: adherence, follow-up, diet, substance use, and the countless small decisions that accumulate over time into health or illness. Without engaging those, the label remains a description, not a solution. Simply giving the undomiciled a house would not make an abused body healthy, for it would not change any part of the lifestyle of homelessness. Rather, I predict, it would nearly immediately destroy what was previously a perfectly nice house.

The defenders of this system will object, and their objection deserves a direct answer. The argument goes as follows: even if these conditions are not diseases in any strict sense, documenting them serves a clinical purpose. It alerts the care team. It triggers social work referrals. It connects patients to community resources. The physician who sees only the sore throat, the argument continues, misses the forest for the trees.

This is not an unreasonable position. It would be convenient if it were supported by evidence. It is not, at least not in any robust way. The published literature on SDOH documentation in electronic records shows consistent improvement in one category of outcome: process measures. Screening rates go up. Referrals are generated. Boxes are checked. What the evidence does not reliably show is improvement in actual health outcomes or reductions in healthcare utilization and cost. A systematic review examining 28 studies, half of which were randomized controlled trials, found that while patients demonstrated improved access to resources after SDOH screening interventions, findings on the effects on health outcomes and cost were mixed.1 Generating a referral and improving a patient’s health are not the same thing, and the literature treats them as interchangeable far too often.

This matters because the entire justification for mandatory, non-removable SDOH documentation rests on the assumption that documentation leads to action and that action leads to better outcomes. The first link in that chain is weak. Even proponents of EHR-based SDOH integration acknowledge that the evidence base remains limited, and that barriers to actually capturing codes and connecting patients to resources persist despite the presence of documentation infrastructure.2 The second link is weaker still. There is, as yet, no compelling demonstration that routine SDOH documentation in emergency or acute care settings produces meaningful improvements in the chronic social conditions it purports to address.

The financial architecture underlying this effort makes the situation worse. CMS has now elevated housing instability codes to “complication or comorbidity” status under the Medicare Severity Diagnosis Related Groups payment system, directly tying SDOH documentation to higher inpatient reimbursement.3 The incentive is therefore not to improve the patient’s housing situation. The incentive is to document that the housing situation exists, collect the additional payment, and move on. One should not be surprised when a system optimized for documentation produces excellent documentation.

The broader MIPS framework, of which SDOH reporting is now a component, has already been shown to operate this way. A 2022 study in JAMA examining more than 80,000 primary care physicians found that MIPS scores were inconsistently associated with performance on clinical process and outcome measures, and that physicians caring for more medically complex and socially vulnerable patients were more likely to receive low scores despite providing high-quality care.4 A metric that systematically disadvantages physicians who treat the most difficult patients while rewarding documentation compliance is not a quality metric. It is an administrative exercise. Appending social determinants to that exercise does not redeem it.

There is also a more immediate objection, one that will be familiar to any emergency physician. The argument for SDOH documentation assumes a continuity of care in which a flag placed in the record propagates meaningfully through a system. In the emergency department, that assumption fails almost entirely. The patient presenting with chest pain at two in the morning will be seen, treated, and discharged or admitted on the basis of the clinical picture in front of me. The fact that my note begins with his BMI, placed there automatically and without my input, does not trigger a nutritional intervention. It does not prompt a behavioral health referral that would not otherwise have occurred. It does not change his diet on the drive home. It sits in the chart, contributes to a complexity score, and supports a billing calculation. The patient is not meaningfully better for it.

None of this is an argument against social workers, community health programs, or genuine efforts to connect vulnerable patients with resources they need. Those efforts have value, and physicians who work in continuity practices have reasonable tools to pursue them. The argument is against the specific practice of encoding social circumstances as automatic diagnoses in the medical record, presented as equivalent to clinical findings, non-removable by the treating physician, and justified primarily by a reimbursement incentive rather than demonstrated patient benefit.

Social conditions influence health. They do not determine it. To speak as though they do is to misunderstand both the evidence and the patient. It replaces a complex human being with a simplified model, and it builds a system around that model. When that system is then reinforced by financial incentives that reward documentation rather than outcomes, the distortion compounds. The chart becomes more complete on paper and less faithful to reality.

What is lost in this arrangement is the physician’s most basic function: to meet the patient in front of him with clear eyes and accurate language. The automatic diagnosis forecloses that encounter before it begins. It tells the physician what he thinks before he has examined anyone. It tells the patient, implicitly, that his circumstances explain him, that the system has already accounted for what ails him before he has said a word. This is not medicine practiced in service of the patient, but rather, in service of the ledger.

The correction does not require abandoning concern for patients who face genuine hardship. It requires only honesty about what medicine can and cannot do, and about what the record is and is not. A chart is a clinical document. It should reflect what the physician observed, assessed, and decided. When it is converted into an instrument of social accounting, it serves neither function. The physician loses authorship of his own reasoning. The patient loses the physician who might otherwise have attended to him without a predetermined conclusion already entered at the top of the page.

Medicine’s defenders of neutral language mistake the absence of judgment for the presence of compassion. But judgment is precisely what the physician does. He distinguishes, draws distinctions, decides. A clinical vocabulary deliberately emptied of evaluative content is not a kinder vocabulary; it is an emptier one, and ultimately a less honest one. When we describe a circumstance as a diagnosis, we commit ourselves to a set of assumptions about cause, mechanism, and responsibility. Those assumptions have consequences, for how patients are understood, for how resources are allocated, and for what kind of care is actually delivered. The terminology of social determinism, embedded now in the electronic record by regulatory mandate, carries assumptions that do not survive scrutiny. Medicine should insist on better.

The rationale appears straightforward. A patient with a potential cervical spine injury should have the neck immobilized to prevent further damage. This logic is intuitive and has been repeated for decades. It feels cautious, prudent, and safe. But intuition is not evidence, and the evidence for routine cervical immobilization is remarkably thin.

A Cochrane review examining spinal immobilization in trauma patients found no randomized controlled trials demonstrating that the practice improves neurologic outcomes, and concluded that there is insufficient evidence to support its routine use.1 The absence of high-quality evidence is a reflection of how deeply ingrained the practice had already become before modern standards of evaluation were applied. The most frequently cited comparative study, examining trauma systems in Malaysia, where immobilization was not routinely practiced, and New Mexico, where it was, found no reduction in neurologic injury with immobilization and in fact reported less neurologic disability among patients who were not immobilized.2 While not definitive, such findings directly challenge the intuitive premise that immobilization prevents secondary spinal cord injury.

At the same time, the harms of cervical collars are well documented. They increase intracranial pressure in patients with head injury, complicate intubation and advanced airway management, and impair respiratory mechanics.3 Prolonged use is associated with pressure ulcer formation and patient discomfort, particularly in populations for whom proper fit is difficult to achieve.4

These are not rare or theoretical complications. Rigid collars are frequently inapplicable in the patients most likely to present after trauma: the elderly patient with cervical kyphosis for whom proper fit is anatomically impossible, or the obese patient in whom the device provides no meaningful restriction of motion whatsoever. In the agitated patient with head injury, forced compliance with a rigid collar may itself provoke the very cervical movement the device is meant to prevent. The harms are concrete and documented; the benefits remain unproven.

It is therefore notable that several developed systems have already begun to move away from routine immobilization. Guidelines in the United Kingdom and elsewhere now emphasize selective spinal motion restriction rather than universal application of rigid collars.5 The persistence of routine immobilization in the United States, despite weak evidence of benefit and clear evidence of harm, suggests that forces other than patient outcomes are driving the practice.

To understand why, one must look beyond physiology and into incentives. The persistence of cervical collars is not a triumph of evidence-based medicine. It is a product of the highly litigious system in which American emergency physicians serve. It is purely an exercise in defensive medicine.

The physician evaluating a trauma patient faces a familiar asymmetry. If a collar is applied unnecessarily, the patient experiences discomfort and perhaps minor harm. These consequences are diffuse, rarely documented, difficult to prove, and therefore essentially never litigated. If a collar is not applied and the patient is later found to have a cervical spine injury, the consequences are entirely different. Even if the omission had no causal role in the outcome, the narrative is already written. A simple intervention was not performed. Standard of Care was not upheld. A catastrophic injury followed. The case is a slam dunk.

This asymmetry drives behavior. It is not that physicians believe strongly in the efficacy of cervical collars. It is that the legal risk of omission overwhelms the clinical ambiguity of benefit. The collar becomes a form of malpractice insurance, worn by the patient but purchased by the physician.

The legal pressure surrounding cervical spine injuries is real. Missed or delayed diagnosis of cervical spine trauma has long been recognized as a recurring source of malpractice litigation, often involving severe and irreversible neurologic outcomes.6 In such cases, the clinical nuance of whether immobilization would have altered the outcome is rarely the central issue. What matters is that a recognizable precaution was omitted. The absence of a cervical collar is easily framed as a deviation from standard practice, regardless of whether its application would have provided any meaningful protection. This dynamic is reinforced by a broader malpractice environment in which physicians routinely report ordering interventions primarily to reduce liability exposure rather than to benefit the patient.7 Even as professional organizations move toward more selective approaches to spinal motion restriction, they acknowledge that medicolegal concerns remain a significant barrier to change.8 The result is a system in which the visible act of precaution carries more legal weight than its clinical value.

The cervical collar is not unique. It is simply one of the most visible examples. Similar patterns appear throughout emergency care. Patients are placed on telemetry without clear indication, not because monitoring is expected to change management, but because the absence of monitoring is difficult to defend if an arrhythmia is later discovered. Rigid backboards, long known to cause pain and pressure injury, persisted for decades after their benefit was questioned, sustained more by protocol than by evidence. Even clinical decision tools, designed to support judgment, are often repurposed as documentation. Scores such as HEART, Wells, PESI, CURB-65, and NEXUS are frequently applied not to guide a decision, but to justify one already made, creating a record that the appropriate pathway was followed. Diagnostic testing follows the same logic. Low-risk patients undergo stress testing or coronary CT not because these tests meaningfully reduce the risk of myocardial infarction in that population, but because a normal result is legible reassurance in the chart. In each case, the intervention persists not because its benefit is clear, but because its omission is visible in retrospect.

This is particularly striking because physician judgment alone often performs remarkably well. In many studies, clinician gestalt rivals formal risk stratification tools in its ability to rule in or rule out serious disease. For example, one prospective study comparing physician gestalt to the HEART score in undifferentiated emergency department chest pain found no significant difference in overall diagnostic accuracy between the two approaches.9 Experienced physicians are reliably able to identify low-risk patients with accuracy comparable to that of the algorithms and tests later used to validate the decision. Yet gestalt alone is not considered defensible. A physician may accurately recognize that a patient is not suffering from acute coronary syndrome, pulmonary embolism, or cervical spine injury, but clinical judgment without objective documentation carries little legal protection. The test, the score, and the protocol are therefore not merely diagnostic instruments. They are evidentiary ones. In the courtroom, the physician’s expertise is often treated as subjective intuition, while the algorithm and the scan are treated as proof of diligence and concern. The irony is that both may arrive at the same conclusion, but only one reliably protects the doctor. A system that treats clinical expertise as legally inferior to algorithmic output does not merely inconvenience physicians; it communicates to them that their judgment is not worth cultivating.

Other countries, operating in less adversarial legal environments, have translated this evidentiary skepticism into formal policy. The United Kingdom’s NICE guidelines, updated in 2016, replaced the presumption of universal collar application with a structured clinical decision framework: patients are assessed using the Canadian C-spine Rule, and immobilization is applied selectively based on documented risk factors, not reflexively applied to every patient with a plausible mechanism of injury.10 Norway went further still. Its 2016 national prehospital guidelines explicitly recommended against routine collar use, proposing instead a tiered approach in which manual in-line stabilization, head blocks, and selective collar application are deployed based on clinical assessment, with penetrating trauma patients explicitly excluded from immobilization altogether.11 The principle underlying both frameworks is the same: a trained clinician, applying a validated decision tool, can identify which patients require immobilization and which do not, and the absence of a rigid collar in the latter group does not represent negligence. It represents judgment. The difference between these systems and the American one is not that physicians abroad are less concerned about patient safety. It is that their legal and professional environments allow clinical judgment to carry moral and institutional weight, rather than treating it as a liability to be insured against with hardware.

In the United States, that fear is ever-present. It shapes decisions in ways that are often invisible to those outside the profession. Policy discussions about healthcare costs frequently focus on administrative overhead, pharmaceutical pricing, or insurance structures. These are real issues, but they overlook a quieter and more pervasive force. The constant anticipation of litigation alters behavior at the bedside. It encourages interventions that are legally defensible rather than medically necessary.

Cervical collars are a particularly clear example because they are so visible. One can see them in every trauma bay, on every stretcher, on nearly every patient with even a remote possibility of injury. They are a physical manifestation of a legal environment that rewards excess caution when that caution is easy to explain, regardless of its clinical value.

When a practice persists despite weak evidence and known harms, one must ask what sustains it. In this case, the answer lies not in medicine but in law. The broader point is that defensive medicine is a structural feature of the system. It operates continuously, shaping thousands of small decisions that accumulate into significant cost and complexity. Many of these decisions, like the application of a cervical collar, appear minor in isolation. Collectively, they represent a substantial distortion of medical practice.

The system does not reward restraint. It punishes it. A physician who exercises judgment and omits an unnecessary intervention assumes a risk that is not shared by the physician who applies it reflexively. The result is predictable. Excess becomes standard, and deviation from excess becomes liability.

Any efforts to control healthcare costs that do not address the legal environment are destined to fall short. As long as physicians are judged not only by what they do, but by how their actions can be reconstructed in a courtroom, the incentive will be to do more rather than less. The marginal test, the precautionary intervention, the unnecessary device will continue to proliferate.

For now, the collar stays on, but it does not protect who it claims to.

This essay is the third of a series on defensive medicine.
Part 1: The Price of Torts
Part 2: The Alienated Patient

MIPS is a federal pay-for-performance program administered by Medicare. It was created with the stated aim of rewarding high quality care and financially penalizing low quality care, as defined by the federal government through a set of measurable metrics intended to indicate whether care was good or bad. Clinicians are scored across several categories, including quality measures, cost, improvement activities, and use of electronic health records. These scores are combined into a composite performance score that determines future payment adjustments. High scores yield modest bonuses of about one percent, while low scores result in penalties that can reach nine percent of total Medicare reimbursement. Participation is therefore not optional in any meaningful sense, as noncompliance or poor performance directly reduces revenue.

We learned of the change a quarter of the way into the performance year. At the time of notification, we had not been told which quality metrics would be used to evaluate us. We had no data on our current performance, no reporting infrastructure in place, and no ability to assess our exposure. We were told that a dashboard would eventually be built to track our compliance, but that the relevant measures would not be integrated into the electronic medical record until midway through the year. We were, in effect, already being judged by criteria we could not yet see.

The financial consequences are substantial. Under MIPS, reimbursement penalties can reach nine percent. Medicare accounts for approximately forty percent of our emergency department revenue. The potential exposure is therefore roughly five percent of total revenue. For a physician group, that magnitude represents a meaningful threat to stability and may force contraction.

The work required to participate in this program occurs almost entirely outside the bedside. In the first half of March alone, our group participated in four separate meetings, each approximately two hours in duration. Nearly every physician attended. These meetings also included representatives from information technology, billing and coding, documentation specialists, and senior hospital leadership. Present at various points were the hospital’s Chief Operating Officer, the Chief Medical Officer, the Chief Nursing Officer, the Chief Administrative Officer, and the Chief Population Health Officer. Several of these highly-positioned (and highly-compensated) individuals were learning about MIPS for the first time during these discussions. Eight hours of physician time were consumed in a single month. For a group of thirty physicians, that is approximately 240 physician-hours diverted away from patient care. This figure excludes the time of administrators, analysts, and IT personnel, all of whom are compensated at professional salaries. The output of this effort consisted entirely of coordination around documentation.

If one assigns even a conservative value to physician time, the cost becomes immediately visible. At an estimated $250 per hour in professional productivity, 240 physician-hours represents approximately $60,000 in a single month devoted solely to meetings about compliance. That figure reflects only the opportunity cost of physicians sitting in conference rooms rather than seeing patients, and only for one single department within a single hospital containing dozens of others.

This math excludes the salaries of the administrators in those same meetings, the time of IT staff building reporting infrastructure, the cost of electronic medical record modifications, and the licensing fees for reporting software and external vendors. It also excludes the ongoing inefficiencies introduced into daily practice, including additional documentation requirements, automated prompts, hard stops, and workflow interruptions that slow physicians during clinical shifts. It excludes the salaries of compliance officers, analysts, and consultants whose roles exist primarily to satisfy reporting requirements.

It further excludes the parallel administrative apparatus on the government side, where large numbers of employees design, monitor, and enforce the program, supported by long-term compensation structures, such as government pensions, that extend well beyond their period of active work. This single program operates across tens of thousands of hospitals and health systems, each with numerous departments engaged in reporting, yet it represents only a minuscule fraction of the broader healthcare regulatory framework. When considered in full, the sheer scale of the administrative burden becomes difficult to fully appreciate, and the total cost reaches numbers so high as to be comprehensible only in the abstract.

MIPS requires performance across a large set of hundreds quality measures, but the score is calculated based on a group’s top six metrics. In practice, therefore, groups select six measures to pursue. The rational strategy favors measures that can be satisfied with the greatest reliability rather than those with the greatest clinical importance. For example, one of the available measures requires that when a physician refers a patient to a specialist, the referring physician receives documentation from the specialist visit. In a primary care setting, this has some intuitive appeal. In emergency medicine, the relevance is minimal. The emergency physician does not maintain a longitudinal relationship with the patient and does not require ongoing updates to manage future care.

The measure can nonetheless be satisfied perfectly. All that is required is an automated process within the electronic medical record that routes the specialist’s note to the referring physician’s inbox. Once this is built, compliance approaches one hundred percent. Whether the physician reads the note has no bearing on compliance. Whether the information alters patient care has no bearing on compliance. The metric is fulfilled. This example reflects a broader pattern. The optimal strategy is to identify measures that can be automated or satisfied through templated documentation. Hospitals across the country converge on this approach. The resulting system prioritizes what can be meaninglessly automated over what is clinically consequential.

Many proponents claim that such programs improve quality. That argument depends on equating quality with documentation, data capture, and compliance. Clinical outcomes instead depend on timely recognition, sound judgment, and effective intervention. A completed field in the chart does not change the course of sepsis. An electronically closed referral loop does not prevent myocardial infarction. MIPS focuses on proxies and artifacts of the documentation process and rewards the capacity to generate compliant data.

The resources required to sustain this system are substantial. Hospitals employ quality departments, compliance officers, data analysts, and IT specialists to manage reporting requirements. External vendors sell software and consulting services to facilitate submission. Physicians devote time to meetings, documentation changes, and attestation processes. These costs are incorporated into the price of care. They may appear as higher charges, reduced staffing at the bedside, or longer wait times as resources are diverted from direct patient care to administrative compliance. The patient does not see the machinery, but the patient does experience its consequences.

Faced with financial penalties, rational actors respond predictably. Physician groups and hospitals select measures that can be satisfied with certainty. They invest in automation, modify documentation templates, and hire personnel to ensure compliance. Reengineering clinical care to satisfy abstract metrics would require far greater effort and would be far less measurable. The system therefore rewards the appearance of quality rather than its substance.

MIPS was conceived as a mechanism to reward value. In practice, it has created a parallel industry devoted to demonstrating value. Medicine now devotes increasing resources to proving that care is being delivered according to prescribed metrics. Those resources are finite. Every hour spent in a compliance meeting displaces time that could be spent with patients. Every dollar spent on reporting infrastructure displaces investment in clinical capacity. The cost is real. It is borne by physicians, by hospitals, and ultimately by patients. It is the price of measuring what does not matter.

This is the baseline reality in emergency departments across the United States. Neither hospitals nor governments have solved this problem. They have not seriously attempted to. Instead, they have adapted to it.

One of the most common adaptations is the creation of the “Provider in Triage,” often abbreviated PIT. On paper, the role sounds humane. In an overburdened system with long waits, the idea is to place a physician at the front door to keep an eye on the lobby, identify sick patients early, and initiate care while people wait. If you do not work in an emergency department, you might reasonably assume this role exists out of concern for patient safety.

It does not.

Doctors working in the main emergency department already see everything that happens in triage. We see vital signs, nursing notes, lab results, EKGs, and imaging as theyresults. Our computers display trackboards showing every patient in the department, both roomed and in the lobby, along with their vitals, complaints, notes, and test results. We are notified of any critical test result immediately. We do not need to physically sit in a triage chair to “keep an eye on the lobby.”

For decades, triage nurses have been empowered to initiate protocol-driven orders. Chest pain gets an EKG, cardiac biomarkers, and a chest X-ray. Abdominal pain gets “belly labs” and a urinalysis. Shortness of breath gets oxygen, labs, an EKG, and a chest x ray. This is standard emergency medicine practice. It works. It does not require a physician stationed in triage.

The Provider in Triage orders the same tests the triage nurse would order. What the Provider in Triage adds is a physician note.

That note is the entire point.

From the hospital’s perspective, boarding creates two problems. One is clinical. Patients wait. Some deteriorate. Some leave. The other is financial. Patients who leave before being “seen” cannot be billed. Hospitals cannot generate charges without a physician or advanced practice provider note. Nursing care alone is not billable in the same way. If a patient waits for hours, becomes frustrated, and leaves, the hospital absorbs the cost of that encounter, including the testing that the triage nurse ordered and collected.

The Provider in Triage exists to fix this second problem.

By placing a physician in triage to write a brief, billable note on every patient who checks in, the hospital can generate a charge even if the patient leaves without ever receiving real care. The documentation is formulaic. A chief complaint. One sentence of history. An exam that effectively says the patient appears stable from the doorway. An assessment and plan that reads “initial workup ordered, full evaluation when roomed.”

When that patient gets frustrated and walks out, no full evaluation ever occurs, but the chart now contains a physician note. The hospital can bill.

Administrators often justify the Provider in Triage by invoking safety. The physician, they say, can identify the sick patient waiting in the lobby and intervene early. This is a fantasy. If a patient is truly sick, the problem is not recognition. The problem is space. The clinical staff already know the patient is sick, but there is no bed to move them into, no monitor, no nurse, no place to safely provide care. The Provider in Triage cannot fix this. They cannot conjure a room. They cannot create capacity. They cannot turn a chair into an ICU bed.

The only patients the Provider in Triage meaningfully evaluates are those who do not need a room to begin with. Minor lacerations. Viral illnesses. Chronic complaints. Problems that can be discharged quickly without imaging, labs, or prolonged observation. The sick patients remain sick, and they remain untreated.

When physicians are scheduled to work as the Provider in Triage, it is an intensely demoralizing experience. We know why we are there. We know the role is not about care. We know it is not about safety. We know it is not about fixing boarding. We are there to generate revenue from patients who are not receiving real treatment. We are there to ensure that a patient who waited for hours and eventually gave up will still receive a bill for thousands of dollars.

We are there to document an encounter that never truly occurred.

This is moral injury. It is the slow corrosion of professional identity through repeated participation in acts that feel wrong but are structurally demanded. Physicians know that what they are doing is sticking someone with a huge bill, screwing over a patient they know they should instead be helping. The chart will say the patient was seen, and the bill will say the same, but both the patient and the doctor know otherwise.

Rather than addressing the structural failure that traps admitted patients in the emergency department, hospitals have focused on monetizing the waiting room. Rather than restoring capacity, they have optimized billing. This is what institutional failure looks like when it becomes normalized. This is what happens when hospitals are run not by doctors but by corporate managers operating within a vast regulatory bureaucracy. The patient becomes secondary.

The Provider in Triage does not fix the waiting room. It does not move patients upstairs. It does not create beds, nurses, or space.

It does one thing very well.

It makes the waiting billable.

He was a man in his late sixties, previously healthy, the kind of patient emergency physicians quietly hope for. No long list of diagnoses. No brittle physiology. No slow-motion decline.

Days earlier, he had developed chest pain. He treated it like heartburn. Rolaids helped. The pain resolved. He moved on. He developed chest pain again, and this time, he decided to come in. He drove himself. He walked through the lobby. He joked with the front desk staff, people he recognized. He was roomed quickly. The nurses began attaching monitors, starting an IV, obtaining an EKG.

I spoke with him briefly, one or two minutes at most. As the EKG tracing printed, I watched it appear on the screen. It looked like an anterior STEMI, but he had a right bundle branch block, which complicates interpretation. Wide QRS complexes distort ST segments. I pulled up an old EKG from several years prior. The bundle branch block was there then. The ST changes were not.

I turned back toward the patient and his wife. She was already tearful, worried in a way that felt disproportionate to his affect. He was relaxed, almost amused by the attention. As I began to explain that I was concerned he might be having a heart attack, the monitor changed.

First PVCs. Then couplets. Then triplets. Then short runs of ventricular tachycardia.

I asked if he felt anything. Palpitations. Lightheadedness. He smiled and said no. He felt fine.

I started to explain the extra beats and why they worried me. His eyes rolled back. He arrested in front of us.

We began CPR immediately. The family was ushered out. We defibrillated. Gave epinephrine. Lidocaine. Amiodarone. He remained in refractory ventricular tachycardia. During compressions, he perfused well enough to regain consciousness. He pushed against hands on his chest. He moaned. He clenched his jaw. He felt the shocks.

After several rounds, I made the decision to sedate and intubate. I could not justify allowing him to experience that suffering, regardless of the eventual outcome. I gave etomidate and rocuronium and passed the tube. We continued.

At some point, I lost track of time. Twenty minutes. Thirty. Forty. We briefly achieved ROSC, only to lose it again. The rhythm degraded into something between ventricular tachycardia and fibrillation. This was a freestanding emergency department. No cath lab. Our goal was simple and nearly impossible: achieve sustained ROSC, stabilize, and transfer him to a PCI-capable hospital far away.

After nearly an hour, I went to the family. I told them I did not think we were going to get him back. I told them we needed to prepare to stop. They went to an office to grieve. I returned to the room and told the nurses that unless something changed, we would stop at the next pulse check. I asked for objections. There were none.

We continued CPR for two more minutes.

At the next pulse check, he had a sinus rhythm. A strong pulse.

We began post-arrest care, but I waited several minutes before going back to the family. I was convinced he would arrest again at any second. He did not.

When I finally opened the door, I said four words: he has a pulse.

They leapt to their feet. They hugged me. I told them not to thank me yet. I told them we were not out of the woods. I told them we did not know if his brain had survived.

It had.

I could not assess his neurologic status immediately because of the paralytic. But in the ambulance, he woke up. He followed commands. He made eye contact. He mouthed words around the endotracheal tube. He went to the cath lab. He received stents. He went to the ICU. Over the next days, pressors were weaned. He was extubated. He laughed with his family. They sent me a photo of him giving a thumbs up.

He will live with chronic disease as a consequence of this event. But he is alive. Neurologically intact. Present with his family during a season when he would otherwise have been mourned.

I am proud of the outcome. I am proud of the team. But pride is not the dominant emotion this case left me with.

It felt unmistakably like divine intervention.

I had just written an essay titled Proofless about the absence of God in my work. Then I was given a case that defied probability. I have never had a patient suffer a prolonged pulseless arrest at a freestanding emergency department, more than an hour from definitive care, and survive with full neurologic recovery.

Any other day, I would have stopped earlier. Forty-five minutes of CPR is rare outside pediatric arrests. Had I gone to the family even a minute earlier, this man would be dead. Had my internal sense of “enough” arrived slightly sooner, the outcome would have been entirely different.

So many contingencies had to align. He had to come in at all. He nearly turned around when his pain improved in the car. Had he done so, he would be dead. He arrested in front of me. Not in the field. Not unwitnessed. We had mobile ICU transport available. Often, we do not. The day before, a natural disaster had shut down ambulance transfers entirely. The roads had only just been cleared. Had his arrest occurred hours earlier, he would never have reached us.

Medicine presents itself as objective, scientific, governed by protocols and endpoints. In reality, it is filled with gray zones. Decisions are often not decisions at all, but continuations. There is no algorithm for how long to continue CPR, no guideline that tells us at the outset how many minutes a life is worth. We do not decide the duration at the beginning of the arrest. We go until it feels like enough. Until the room feels heavy. Until the interventions feel exhausted and nothing is changing. Until something internal shifts from effort to futility.

That internal sense is not purely clinical. It is shaped by human limits and by the environment in which resuscitation occurs. The emergency department does not pause for a single patient. Other patients accumulate. Alarms continue to sound. Time moves forward whether we want it to or not. Eventually, the question is no longer only whether another round might work, but whether continuing is still justifiable in a department that must keep functioning.

That arbitrariness is difficult to confront.

If this man lived because I continued, who died because I did not? How many outcomes hinge not on guidelines, but on whether the department was busy or short staffed that day, or whether the physician slept well, ate breakfast, felt hopeful that morning? It is an uncomfortable question, and an unanswerable one.

Yet this was not randomness alone. I continued for reasons. He arrested in front of us. He had signs of life. He had a reversible cause. This was not the frail nursing home patient found down with an unknown downtime and no fixable pathology. My judgment was not algorithmic, but it was not blind.

There is no actionable lesson here. No practice change. No algorithm to update. I will still stop when it feels like it is time to stop. I will still continue when there is reason to believe continuing is justified. I cannot eliminate the human element from these decisions, and in some sense I would not want to.

The analytical part of me wants to believe that the outcome was mere good fortune. Sometimes resuscitation works. Rare events are rare, not impossible. Given enough trials, improbable outcomes eventually occur. A prolonged arrest with neurologic recovery does not violate physiology. It merely sits at the far end of the distribution. From that perspective, the timing is coincidence and the outcome is luck. The interventions happened to work this time.

That explanation is tidy, and I am given to prefer tidy explanations.

Yet the same part of my mind that searches for signal in noisy data also resists the idea that randomness is always meaningless. I spend my professional life detecting patterns. I look for coherence where symptoms initially appear disconnected. It is difficult, then, to ignore the temptation to see a pattern here as well.

I have been struggling for some time with the emptiness of my work.

Emergency medicine places you in constant proximity to death and suffering, but paradoxically deprives you of meaning. The majority of my cases fall into two broad categories.

The first is the dwindling patient. Patients who are chronically ill and progressively worsening, with nothing that can actually be fixed. They move between inpatient floors, nursing facilities, and the emergency department in an endless loop. Each visit represents another small step downward. I treat electrolyte abnormalities, infections, fluid overload, confusion. The specifics change, but the trajectory does not. I am not restoring health. I am managing decline. My role is custodial, not curative.

The second category is patients who are not experiencing emergencies at all. They come for anxiety, hypochondriasis, entitlement, convenience, or because they face no financial friction to using the emergency department. They come for second, third, or tenth opinions. They come because outpatient physicians sent them to offload liability. They come because insurance barriers prevent outpatient care and the emergency department is the only remaining access point. Again, the details vary, but the conclusion is the same. They do not need an emergency physician. They need a functioning system, and they do not have one.

After enough years of this, the work begins to feel hollow. I am trained in emergency medicine, yet I treat true emergencies relatively infrequently. When I do, my role is often limited. I recognize a problem, make a phone call, and hand the patient off to someone else for definitive care. In most STEMIs, my involvement lasts minutes. The cardiologist quite rightly receives the credit. I become a conduit, not an agent.

It is difficult to build meaning out of that.

There are days I regret choosing this specialty. It does not pay as well as many others, and it rarely feels more significant. Some days, a quiet cubicle job seems appealing. At least I would have nights, weekends, and holidays with my family. At least the tradeoff would feel honest.

And then this case arrived.

Not only did I witness something extraordinary, I participated in it. Directly. Decisively. In this case, my role was not marginal. It was central. The stents mattered, but they mattered only because the patient was alive long enough to receive them. This time, I did not simply recognize an EKG and make a call. I kept a man alive through a period when almost no one would have expected meaningful survival.

It is impossible not to feel the weight of that.

I cannot escape the sense that this was something like a revelation. Not only for the patient, but for me. The timing was exact in a way that feels difficult to dismiss. Just as he needed to arrive at the emergency department at precisely that moment, avoiding the weather and resisting his instinct to go home and take more antacids, I needed him to arrive in my professional life at precisely that moment as well.

We needed each other.

I do not know what to do with that realization. I cannot operationalize it. I cannot practice medicine differently tomorrow because of it. But I cannot ignore it either. In a profession that so often feels stripped of meaning, this case reminded me that meaning still exists, even if it appears rarely, unpredictably, and without warning.

Perhaps that is the point.

Editor’s note: Some clinical details have been altered to protect privacy.

The Canadian response has been swift and predictable. The explanation offered is that the system is underfunded. The failure, we are told, is not structural but fiscal. The government simply has not spent enough. If more money were allocated, this would not have happened.

The American response has been just as predictable, and just as wrong. Here, the death has been cited as evidence of socialism’s failure. Proof, supposedly, that government-run healthcare leads inevitably to rationing, neglect, and death. The implicit reassurance is that this is a foreign pathology, one we avoid by keeping our system private.

Both explanations are correct on some level, but both are incomplete and ultimately misleading. The Canadian case is not unique to Canada or to socialized systems in general. Patients die in American waiting rooms too.

They deteriorate without monitoring. They collapse unseen. They leave after hours of waiting and return sicker, sometimes fatally so. These deaths rarely become national stories. They are absorbed quietly into statistics and chart reviews, attributed to illness or misfortune, and quickly forgotten.

What makes both responses misleading is that they treat the event as external to the American system, either as a warning about insufficient funding or as a cautionary tale about socialism elsewhere. In reality, the mechanism that killed this patient is already deeply embedded in U.S. healthcare: a phenomenon known as boarding.

Boarding occurs when a patient has already been admitted to the hospital but remains physically stuck in the emergency department because no inpatient bed is available upstairs. The ER has done its job. The diagnosis has been reached, the treatment plan formulated, and the clinical decisions made. The patient is no longer awaiting evaluation but physical space.

Emergency departments are designed for rapid assessment and stabilization, not prolonged inpatient care. When admitted patients cannot move upstairs, they occupy emergency beds indefinitely. Those beds cannot turn over. New patients cannot be roomed. The emergency department ceases to function as an emergency department and instead becomes a holding area for the rest of the hospital, now capable of seeing new patients only occasionally.

This is not a triage problem. It is not caused by people abusing the emergency department with minor complaints. Low-acuity patients can be treated and discharged quickly and do not occupy beds for days. Boarding is a throughput failure, due to a lack of capacity for patients who truly need to be in the hospital.

When admitted patients are stuck in the emergency department, the waiting room becomes the choke point. Patients with undifferentiated, time-sensitive emergencies sit unmonitored in chairs. Ambulances unload patients into lobbies. Delays stretch from minutes into hours to days.

This impacts outcomes. Patients who board in the emergency department receive worse care than those who reach inpatient units. They are monitored less closely. Orders are delayed or missed. Deterioration is recognized later. Complications are more common. Mortality is higher.

The waiting room population suffers as well. Patients deteriorate before ever being seen. Some leave and return sicker. Some collapse unnoticed. Some die.

Most patients never see the real underlying problem. They experience delay without explanation. Even those who are admitted and board in the emergency department rarely understand the real reasons why they are stuck there.

Patients understandably reach for simple explanations: There must be too many sick people. No one wants to work anymore. The hospital is greedy. The government just won’t spend enough money.

These explanations feel intuitive, but they fail to explain a crucial fact. The problem worsens as spending increases.

The United States spends more on healthcare than any society in history. Yet boarding is endemic. Waiting rooms are full. Hallways are lined with stretchers. If money were the solution, this would not be happening here.

The mistake is thinking of socialized medicine only in nominal terms. The United States does not have a single payer system, but it has a small number of dominant payers operating under the direction of a central authority.

The federal government is the largest payer in the system. Medicare and Medicaid set the reference prices. Private insurers do not operate independently. They mirror CMS structures, adopt its coding rules, enforce its metrics, and comply with its regulatory framework. Payment models, documentation requirements, staffing mandates, and capacity rules are centrally dictated and universally imposed.

In practice, the U.S. system is no less collectivized or socialized than Canada’s. It is merely more convoluted.

The result is an even denser bureaucracy, a more labyrinthian regulatory environment, and an enormous administrative class devoted not to caring for patients but to complying with rules, attending meetings, and documenting adherence to ever-expanding mandates.

Once prices are divorced from market forces, money loses its signaling function. Demand becomes effectively unlimited. Supply cannot respond. Capacity cannot expand freely. Labor cannot reprice. Shortage becomes permanent. In such systems, spending more does not create more beds or more nurses to staff them. It just creates more bureaucracy.

Additional funding is absorbed by administrators, compliance officers, consultants, and oversight structures. It pays for meetings about regulations, not nurses at the bedside. It finances documentation systems, not hospital capacity. It expands process, not care. This is why no amount of funding has solved the problem. It cannot. The structure guarantees waste before care.

In functioning markets, rising demand produces higher prices, which incentivize increased supply. Equilibrium is restored. Healthcare has abolished this mechanism while preserving unlimited demand. The result is rationing. In the United States and Canada alike, rationing does not always appear as explicit denial of care. It appears as time.

Boarding is time-based rationing.

The waiting room is where that rationing is enforced.

This is why the crisis persists largely unseen. Policymakers do not sit in waiting rooms. Administrators do not board in emergency departments. Patients experience delay without diagnosis. Only emergency clinicians and boarded patients witness the system failure directly, and even then the cause remains opaque to most.

The tragedy in Canada is a warning, but not about what might happen under socialized medicine should our government someday enact it. It is evidence of what already happens in collectivized systems, including the one we already have.

The younger son demands his inheritance, wastes it in reckless living, and returns in disgrace. The father restores him without hesitation. A robe. A ring. A feast. Music in the house.

The elder son has remained. He has worked. He has obeyed. He has not shamed his father. When he hears the celebration, he refuses to enter. His protest is simple and intelligible. “These many years I have served you… yet you never gave me a young goat.” It is not an extravagant complaint. It is a plea for proportionality.

His grievance does not sound foreign to me.

In medicine, particularly in emergency medicine, I often feel like the elder son. I followed the prescribed path. I deferred income and youth. I studied when others slept. I stayed within the boundaries. I did not squander my body with drugs. I did not abandon children. I did not drink myself into organ failure. And yet much of my professional life consists in cleaning up the wreckage left by those who did.

The overdoses return. The alcoholic bleeds again. The brittle diabetic ignores his regimen and arrives in crisis. The violent man cycles through the department for the fifth time this month. I stabilize. I intubate. I admit. I discharge. I repeat.

It is difficult not to feel that the distribution of effort and reward is inverted. The one who squandered receives urgency, resources, and emotional intensity. The one who remained receives routine. Stability is invisible. Crisis commands attention. The music is reserved for catastrophe and rescue.

I am sensitive to unfairness. Most physicians are. Our moral reflex toward proportion was not formed in the abstract. It was trained into us.

Our careers depended on measurable performance. High grades opened doors. Class rank mattered. Exam scores determined opportunity. A strong transcript led to admission to the next stage. High school performance determined college. College performance determined medical school. Medical school performance determined residency. Residency performance determined fellowship or a first job. At every step, achievement was supposed to be rewarded with advancement.

We internalized that structure early. Effort produced results. Discipline yielded advantage. If a grade was assigned unjustly, it was not a minor irritation. It threatened the trajectory of an entire life. We learned to protest when evaluated unfairly because fairness was not philosophical. It was existential. A single number could close or open a door.

Becoming a physician is a decades-long project built on that premise. Merit mattered. Performance mattered. Proportion mattered. We did not sit quietly when we believed those standards were violated, because our futures depended on them.

The father in the parable did not operate on that logic.

He does not deny the elder son’s faithfulness. He tells him that all he has belongs to him. The inheritance was never at risk. The relationship was never threatened. Yet he still celebrates the return of the one who rebelled.

The scandal of the story is not the forgiveness but the profound asymmetry. Mercy appears to eclipse merit.

There is another discomfort buried here, and it is less noble than I would prefer. The elder son wanted to be seen. He wanted acknowledgment. He wanted someone to notice that he had remained faithful. In my own frustration, it is not primarily the overlooked patient who troubles me. It is myself. I want recognition for the sacrifice.

Medicine demands a great deal. Years of study. Deferred earnings. Missed holidays. Nights without sleep. Exposure to suffering that most people never witness. I chose this path freely. No one compelled me. Yet I still find myself wanting something beyond a paycheck. Yes, physicians are well compensated relative to many professions. But compensation is not the same as honor.

In previous generations, doctors were often regarded with sober respect. Modern medicine was seen as a near miraculous force. The physician stood, however imperfectly, as its representative. That cultural posture has shifted. Many patients remain kind and appreciative. I encounter genuine gratitude every week. But the broader narrative is harsher. On social media and in popular commentary, doctors are portrayed as greedy, as profiteers on suffering, as inattentive, as agents of corporate interests, as pill pushers seeking kickbacks, as technicians who know less than they pretend. It has become fashionable to suspect the motives of the very people trying to help.

I feel that suspicion. I feel it when a patient records an encounter as if preparing for litigation. I feel it when institutional policies imply that my judgment cannot be trusted without layers of oversight. I feel it when the public discourse treats physicians as interchangeable cogs in a profit machine.

It is difficult not to bristle. I want fairness. I want others to say that what I do is hard, and that it matters. I want acknowledgment that skill and discipline were required to stand at the bedside. I do not want merely to be paid. I want to be esteemed.

That desire is not entirely pure. It shades into vanity. The elder son did not simply want his father’s property. He wanted his father’s praise. He wanted visible affirmation that his obedience distinguished him.

The Gospel does not indulge that instinct. Christ speaks of loving those who persecute you, of turning the other cheek, of doing good without expecting return. The standard is not transactional justice but self-giving love. When I read those words, I recognize how far I fall short. I want the ledger balanced. I want respect proportional to sacrifice. I want glory for endurance.

There is something profoundly un-Christlike in that craving. I cannot disguise it as righteous indignation. It is pride. It is a demand to be seen and applauded.

Lent, I think, is meant to strip away those rationalizations. It reveals that my resentment toward the prodigal is entangled with my hunger for honor. I serve, but I also want to be celebrated for serving. I heal, but I want to be praised for healing. I speak about justice, yet I am deeply invested in my own reputation.

The distrust is real. The caricatures are unfair. But the deeper spiritual problem may not be that I am insufficiently appreciated, but that I am too attracted to appreciation. I know how to argue about incentives, agency, and responsibility. I am less comfortable examining my own need for glory.

The elder son stood outside the feast because he believed he deserved something more than proximity. He wanted recognition that separated him from his brother.

I understand him. That is precisely what troubles me. I know the lesson I am supposed to draw. I am supposed to admire the father’s mercy without qualification. I am supposed to rejoice at the sinner’s return. I am supposed to release my ledger and enter the house.

I do not.

I still feel the resentment. I still want fairness. I still want the world to say that discipline, restraint, and sacrifice matter. I still want glory. If I am honest, I am not convinced the elder son is wrong to want those things. He worked. He remained. He bore the weight of responsibility while his brother chased pleasure. There is justice in his protest. He is reasonable in his demand to be seen.

I know that my religion calls me beyond that calculus. I know that mercy is not a market and that love does not tally goats. I know the standard.

But I am not persuaded in my bones.

I do not stand inside the feast. I stand in the field, arms crossed, hearing the music, unconvinced. I remain the elder son, and I am not sure I want to go in.

That narrative is wrong. Not because medicine is free of error, and not because care is always good. The problem also is not merely methodological, although the methodology is weak. The deeper issue is conceptual. These studies quietly redefine what it means to cause death, collapsing the distinction between actively harming a patient and failing to rescue one from a lethal disease process. That distinction is foundational to medicine, law, and moral reasoning. Erasing it produces impressive numbers at the cost of intellectual honesty. In doing so, they mislead the public and distort how medicine is judged.

The 2016 BMJ paper is the origin of the headline. Makary and Daniel did not examine individual deaths or review patient charts. Instead, they reviewed prior literature estimating preventable adverse events among hospitalized patients, extrapolated those estimates to national admission data, and concluded that medical error would rank third among causes of death if it were included on death certificates. Because medical error is not currently coded as a cause of death, they proposed that it should be.

That proposal quietly reframed the question. Rather than asking how many patients die from disease despite medical care, the paper asked how many deaths occur in the presence of care that was imperfect. Those are not equivalent questions. The leap from the latter to the former is what allows medical error to be rhetorically elevated to the status of a leading cause of death, even though no new deaths are identified and no causal mechanisms are demonstrated.

The 2023 Johns Hopkins diagnostic error study follows the same pattern, albeit with more refined modeling and narrower scope. The study does not examine actual patients. It does not review charts, reconstruct clinical timelines, or adjudicate physician decision-making. Instead, it begins with national incidence estimates for a selected group of serious diseases and applies assumed diagnostic error rates derived from heterogeneous prior studies. It then assumes that a portion of resulting deaths or permanent disabilities would have been prevented with earlier diagnosis and attributes those outcomes to diagnostic error. Through a series of statistical transformations, they arrive at an estimate of how many patients experience “serious harm,” including death, attributable to diagnostic error.

At no point do the authors demonstrate that any specific patient who died experienced a missed diagnosis. At no point do they show that earlier diagnosis would have changed the outcome for any individual. The patients counted are statistical abstractions. The attribution of error is assumed rather than observed, and the preventability of death is presumed rather than proven. The deaths are hypothetical in the only sense that matters clinically: no one can say whether any given person who died was misdiagnosed, diagnosed late, or diagnosed as early as was reasonably possible.

The second problem follows directly. Even if some proportion of patients experienced delayed or missed diagnoses, the study assumes that earlier diagnosis would have prevented death or permanent disability. That assumption is doing nearly all of the moral work in the analysis, and it is unsupported.

Many of the conditions included in the model carry substantial mortality even under ideal circumstances. Sepsis kills despite rapid recognition and guideline-concordant care. Stroke outcomes vary widely even with immediate intervention. Aggressive cancers often progress lethally regardless of detection timing. Earlier diagnosis does not guarantee rescue. To treat all delayed diagnoses as preventable deaths is to confuse possibility with probability and hope with causation.

But even these flaws are secondary to the most important error, which is categorical rather than statistical: the conflation of failing to rescue with actively causing death.

Even if every assumption in the study were granted, even if every death counted represented a real patient who received suboptimal care, it would still be incorrect to say that doctors killed those patients.

A physician who fails to rescue a patient from a lethal disease has not caused that patient’s death. The disease is what has killed the patient. This distinction is foundational to medicine, law, and moral reasoning. It is the difference between action and inaction, between harm inflicted and harm not averted.

If a physician administers a lethal medication, performs a wrong-site surgery, or introduces a harmful intervention that directly kills a patient, then the physician has caused the death. That is iatrogenic harm. If a physician fails to diagnose a disease in time to prevent its progression, the physician may have provided poor care. The physician may even have committed malpractice. But the cause of death remains the disease.

Failure to stop a process is not the same as initiating it. This distinction is not semantic. Medicine is not an obligation to guarantee survival. It is an attempt, under uncertainty, to alter probabilities. When that attempt fails, the failure does not retroactively convert disease into homicide.

None of this is a denial that bad care exists. Diagnostic error, missed diagnosis, and delayed diagnosis are real phenomena. They can reflect incompetence. They can constitute malpractice. They can prolong suffering, and in some cases directly worsen outcomes. A substantial portion of modern medicine is practiced under political, financial, corporate, and bureaucratic constraints that actively obstruct good care even when competent physicians are prepared to provide it. Much of my own work has focused on precisely these failures and on the policies and incentives that make them more common than they need to be.

Acknowledging those realities, however, does not require accepting the claim that medicine itself is a leading cause of death. Bad care does not automatically imply causative killing. Poor performance, systemic obstruction, and even negligence do not transform disease mortality into physician homicide. One can condemn malpractice without rewriting the cause of death.

The distinction matters because medicine operates under uncertainty. Earlier diagnosis improves probabilities. It does not guarantee survival. Retrospective certainty does not imply prospective negligence. To treat every bad outcome as proof of culpability is to deny the probabilistic nature of clinical care.

There is a simple counterfactual test that exposes the flaw in the “medical error kills” narrative. Would these patients have been better off had they never sought medical care at all?

For the deaths counted in these studies, the answer is plainly no. These studies are not about healthy patients who are killed by a physician administering a poison or surgically removing a vital organ by mistake. These are patients who were sick and dying from a disease, and the supposed error is that their trajectory was not identified and reversed quickly enough. Clearly, had these patients stayed home, avoided hospitals, and never encountered physicians, they still would have died of the same diseases. The outcome would have been unchanged. The only difference is that their deaths would have been recorded honestly, as deaths due to sepsis or cancer or stroke, rather than reassigned after the fact to the category of medical error.

A cause of death cannot coherently be labeled a medical error if the outcome is identical in the absence of medical care. To suggest otherwise implies that abolishing the healthcare system would reduce mortality by eliminating diagnostic delay. That conclusion is absurd, yet it is the logical endpoint of the third-leading-cause framing.

The popularity of this narrative cannot be separated from a broader cultural shift. Patients are increasingly told that they are entitled to medical care, that they should not have to pay for it directly, and that it should be comprehensive, immediate, and effective regardless of circumstance. Lifestyle choices are treated as morally neutral. Outcomes, however, are treated as obligations owed.

Within that framework, death becomes unacceptable. If care is a right and care is assumed to be capable of saving you, then dying must represent a failure. And if it is a failure, someone must be responsible. Reframing deaths from disease as deaths due to medical error implicitly asserts that patients have a right not to die from these conditions and that if they do, it must be someone else’s fault.

But no such right exists. There is no entitlement to rescue from biology. Medicine can alter probabilities, not abolish mortality. Treating death as evidence of wrongdoing is a denial of biological inevitability.

This entitlement logic also explains why compensation is so often reframed as greed. If medical care is a right, then those who provide it are not offering a service but discharging an obligation. To expect payment for fulfilling an obligation appears immoral. To fail in that obligation appears culpable. Physicians are thus cast as both indispensable and suspect, powerful enough to save lives yet morally obligated to do so on demand.

The downstream consequences are already visible. When every bad outcome is framed as error and every error as culpability, clinicians respond rationally. They practice defensively. They order excessive tests, pursue low-yield imaging, and follow rigid protocols not because they believe these actions improve care, but because documentation and conformity provide legal shelter. Over time, judgment gives way to checklists, and experience yields to algorithms.

Algorithmic medicine is often presented as progress. In reality, it is a shield. It offers protection against liability by allowing clinicians to say they followed the pathway, even when the pathway is poorly suited to the individual patient. In a culture that treats death as evidence of wrongdoing, discretion becomes dangerous. Deviation becomes reckless. Human judgment becomes a liability.

The claim that medical error is the third leading cause of death persists not because it is true, but because it satisfies a cultural demand. It reassures the public that death is optional, that survival is owed, and that when biology prevails it must be because someone else failed.

The 2016 BMJ paper and the 2023 Johns Hopkins modeling study do not show that physicians are killing patients. They show that disease remains lethal despite medical care and that medicine operates under uncertainty with imperfect tools. Reframing those limits as culpability does not make care safer but rather more dishonest.

Medicine cannot promise rescue. It can offer effort, skill, and probability, but not guarantees. A society that treats every death as a failure and every failure as a moral offense will not eliminate mortality. It will only ensure that fewer people are willing to accept the responsibility of trying to fight it.

What is mischaracterized is the claim that drug use is primarily a medical problem rather than a moral or criminal one.

Drug users are not innocent victims struck by a disease that arrives unbidden. Using heroin is not analogous to developing leukemia or being struck by lightning. The presence of neurochemical reinforcement does not negate agency. It explains why drugs are pleasurable and why stopping is difficult, but difficulty is not the same as involuntariness.

Addictive substances act primarily through dopamine. That is not incidental. Dopamine is the neurochemical correlate of reward, motivation, and reinforcement. Drugs are addictive because they feel good. They produce pleasure, relief, or escape, and the brain learns to pursue those effects. But dopamine is not a master that enslaves the will. Every human being is driven by dopamine to some extent. We still make choices. We still prioritize. Dopamine is what underlies every temptation, but what determines whether one gives in is character.

Drug addiction reveals priorities. It demonstrates that the pleasure derived from the drug has been elevated above competing goods: family, work, health, dignity, legality, and often the well-being of others. Addicts routinely show a willingness to sacrifice all of these in pursuit of the high. That willingness is not imposed externally. It is revealed in the choices the addict makes, repeatedly, over time.

Once addicted, stopping is undeniably hard. Cravings are powerful. Withdrawal is miserable. Relapse is common. None of this converts drug use into an involuntary act. We routinely expect people to resist powerful biological drives when acting on them would harm others. Hunger, anger, sexual desire, and fear all have biological substrates. They do not absolve behavior.

The modern insistence that addiction is a disease functions less as a scientific insight than as a moral anesthetic.

Labeling addiction as a disease replaces moral language with clinical euphemism. Words like vice, self-indulgence, irresponsibility, and neglect are displaced by phrases such as substance use disorder, maladaptive coping, and chronic relapsing illness. The effect is not greater understanding but moral evasion. Behavior that would once have been condemned is now viewed with clinical neutrality.

This reframing allows physicians, policymakers, and institutions to feel compassionate while avoiding uncomfortable truths about choice, self-control, and obligation. Yet judgment does not disappear. It is merely displaced. Someone must still decide whether behavior is tolerated, subsidized, punished, or restrained. The disease model simply denies that these decisions are moral decisions at all.

The disease framing also depends on a striking asymmetry in how agency is treated. Drug users are routinely portrayed as incapable of responsibility when harms occur. Theft, assault, child neglect, impaired driving, and public disorder are attributed to compulsion. Responsibility is attenuated or erased. Yet the same individuals are assumed to possess full autonomy when demanding services, housing, legal leniency, or even continued access to narcotics through substitution programs. Agency vanishes when blame is at stake and reappears when entitlements are demanded.

This inconsistency is politically useful. It permits endless provision without accountability. But it is incoherent. Either drug users possess agency or they do not. Acts cannot be involuntary only when convenient.

Perhaps the most corrosive effect of the medicalized narrative is the inversion of victimhood it produces. The addict is centered as the primary victim, while those harmed by drug use fade into the background. Families endure theft, violence, neglect, and emotional devastation. Children are placed into foster care. Neighborhoods decay under the weight of open drug use, vandalism, and disorder. Small businesses absorb losses. Pedestrians and drivers are killed by impaired operators. Taxpayers fund remediation for damage they did not cause.

These victims are diffuse and anonymous. They lack advocacy organizations and sympathetic media narratives. The addict, by contrast, is visible and endlessly foregrounded. Compassion is concentrated toward the person causing harm, while those bearing the harm are rendered invisible.

If addiction were primarily a medical disease, outcomes should improve as treatment expands. Instead, despite unprecedented investment in harm reduction, pharmacologic substitution, public health outreach, and social services, morbidity, mortality, homelessness, and drug-related crime have worsened. Treating addiction as a disease encourages management rather than resolution. It assumes chronicity, normalizes relapse, and lowers expectations. The goal shifts from cessation to mitigation, and damage accumulates accordingly.

Policies designed to avoid stigma often entrench addiction by removing consequences that historically constrained destructive behavior. Decriminalization, permissive enforcement, and unconditional tolerance are framed as humane but in practice are indistinguishable from abandonment. Consequences are not merely punitive but instructive and corrective. They communicate boundaries, and removing these boundaries does not liberate people from their addiction. It leaves them alone with it.

Medicine is not a neutral participant in this process. Expanding the disease label enlarges medicine’s jurisdiction, budgets, and authority. Every behavior reclassified as pathology becomes an opportunity for billing, research funding, and institutional relevance. Pathologizing behavior is safer than confronting it. It avoids moral controversy while expanding professional control.

I did not always hold these views. I once favored legalizing drugs and treating drug use as a primarily medical rather than criminal problem. I believed drug use was largely a victimless crime. That belief eroded when states began legalizing a drug widely regarded as benign: cannabis.

The consequences have been impossible to ignore. Cities now smell constantly of skunk. Drug use has skyrocketed. Otherwise functional adults have been encouraged to use cannabis products under the assumption that they are safe. Meanwhile, the product itself has changed dramatically. Cannabis is no longer a low-potency plant grown by amateurs. It has been industrialized, concentrated, and optimized by corporate and pharmaceutical interests. THC concentrations have risen far beyond anything historically typical.

With this shift has come pathology that was once rare or essentially unknown. Cannabinoid hyperemesis syndrome is now a routine diagnosis. I see multiple patients with this condition every day in the emergency department. It was virtually unheard of prior to legalization. What was marketed as harmless, marketing which I admit had previously fooled me, has produced immense harm.

The philosophical justification for drug legalization rests on the claim that drug use is a legitimate lifestyle choice rather than a moral failure or a crime. That claim, in turn, rests on the idea that drug use is victimless. Our society increasingly believes that anything consenting adults engage in cannot be immoral, that consent alone is sufficient for moral permissibility.

This belief emerges from a deeper cultural shift. We are no longer religious. We no longer believe that life has a given purpose or trajectory, or that we are accountable to anything beyond our own preferences. Instead, we believe our lives exist for our own fulfillment and pleasure. So long as we do not directly violate the rights of others, all choices are treated as morally equivalent. Working or playing video games, raising children or not, pursuing excellence or chemical escape. These are all regarded as interchangeable lifestyles. We owe nothing to the future. We owe nothing to each other beyond noninterference.

This is a deeply flawed vision of human life.

A life spent pursuing chemical pleasure is a life poorly lived. I do not concede that an act must have a direct victim to be immoral. Some choices are better than others even in isolation. A society that refuses to make such distinctions cannot sustain itself.

Even if one accepts the premise that there are no victimless crimes, drug use still fails the test. The image of a solitary individual harming no one in private is a fantasy. In reality, the effects of drug use inevitably spill outward. Even highly functioning users compromise their ability to meet obligations to their families, employers, colleagues, and communities. A society with widespread drug use becomes unreliable, disordered, and brittle.

Drug use is not something that merely happens to people. It is something people do, again and again, with foreseeable consequences, to themselves and more importantly, to others. We must stop pretending otherwise.

This is not because physicians are cruel or indifferent. It is because we are uncomfortable naming agency when agency implies blame. Faced with misbehavior, we are taught to soften rather than confront, to translate conduct into category, to convert choice into symptom. The diagnosis becomes a way to continue walking without having to say what we know. The patient behaves badly, therefore the patient must have a disorder. The behavior is reframed as a symptom of a disease, thereby excusing it and removing the sense of agency that might otherwise inspire a patient to change it.

This is not compassion. It is avoidance.

Medicine once distinguished between misfortune and misconduct. Today it equivocates, collapsing them into a single clinical category. In doing so it has confused kindness with indulgence and healing with affirmation. Patients arrive not seeking restoration but seeking recognition of a diagnosis, as though the proper label could absolve them of responsibility for their lives. Illness is no longer something one has. It becomes something one is.

Illness has become identity. The transformation is subtle but unmistakable. A diagnosis becomes a badge. A prescription becomes a proof. The disorder becomes the total explanation for everything troubling in a patient’s life, and therefore the patient is exempt from any expectation to change. What once required courage is reframed as what requires treatment. What once called for discipline now calls for documentation. The vocabulary that once described character has been quietly replaced by the vocabulary of disease.

Sloth becomes fatigue.
Pride becomes narcissism.
Wrath becomes conduct disorder.
Gluttony becomes an eating disorder.
Immaturity becomes a neurodevelopmental disorder.

These substitutions do not explain behavior. They merely rename it. Unlike diabetes, which names the pathophysiology that explains hyperglycemia, most psychiatric labels describe patterns of conduct without explaining their origin. “Oppositional defiant disorder” does not identify a disease state that inexorably causes aggression or antisocial behavior. It simply describes a person who behaves in those ways. The behavior comes first. The label follows. Physicians understand this tacitly, yet we hesitate to say it aloud.

That hesitation is moral claudication. We know that diagnosis, in these cases, is functioning as a substitute for judgment, but we proceed anyway. We tell ourselves that nonjudgment preserves the therapeutic alliance. We fear that speaking plainly will poison the relationship. It is true that calling a patient a bad person is neither therapeutic nor appropriate. It is also true that refusing to tell a patient that their choices are destructive is not kindness. It is abdication.

We do not hesitate to speak plainly about smoking. We do not shrink from telling patients that obesity worsens disease. We do not avoid discussing alcohol use when livers fail. Yet when confronted with violence, theft, abuse, or chronic antisocial behavior, we retreat into diagnostic language. We medicalize what we would otherwise condemn. The label softens the interaction, but it also freezes the trajectory. Diagnosis excuses the behavior and, paradoxically, ensures its continuation. We tolerate a certain amount of judgment when it concerns habits, but we flee it when it concerns character.

These new identities make the physician’s task nearly impossible. For patients who have fused diagnosis with selfhood, questioning the diagnosis is experienced as a personal attack. To suggest agency is to commit a kind of heresy. Compassion, as currently practiced, requires unconditional acceptance of the patient’s self-narrative. This is not care but capitulation.

The tragedy is that the system rewards this capitulation at every level. Bureaucracies demand codes, not character. Insurers demand pathology, not virtue. Schools demand accommodations, not expectations. Patients learn that helplessness is a resource. Clinicians learn that challenging helplessness is dangerous. It is far safer to label a behavior than to ask a person to rise above it. Diagnosis becomes permission, and permission becomes destiny.

The ER reveals this dynamic in its starkest form. It sits at the intersection of medical and moral failure. I meet patients whose actions are plainly chosen yet must be treated as involuntary because the system cannot tolerate the idea of willful harm. I meet patients who weaponize fragility because fragility has been taught as power. Families arrive believing that a diagnosis will resolve a moral or spiritual crisis that no medication can touch.

The ER becomes the staging ground for these contradictions. I am asked to intervene in crises that are described as medical but are unmistakably moral. I am asked to manage despair that grows out of meaninglessness, relationships that collapsed under resentment and avoidance, and patterns of behavior that were decades in the making. I am asked to heal what is not medical.

Psychiatry cannot define the full range of human suffering, nor can it account for every form of dysfunctional behavior. There are limits to what medicine can meaningfully address. Medicine can sedate, but it cannot cultivate strength. It can stabilize, but it cannot provide purpose. It can quiet a mind, but it cannot shape a character. These tasks belong to families, communities, churches, mentors, and the moral world that once gave structure to human life. Those institutions have eroded, and medicine has been conscripted to replace them. It is a poor substitute.

We have created a culture in which people cannot be asked to change because change implies judgment, and judgment has been declared the unforgivable sin. Yet healing requires responsibility. It requires the belief that one can choose differently tomorrow than one chooses today. Without this belief, diagnosis becomes fate and care becomes containment.

Compassion is indispensable, but it is not synonymous with nonjudgment. True compassion does not excuse destructive choices. It insists that human beings are capable of better ones. The task of medicine is not to shield patients from this reality but to help them meet it. When diagnosis is used to avoid moral truth, it does not heal. It merely spares discomfort while ensuring decline, allowing the physician to keep walking while the patient remains stuck.

The ER was meant for children with illness or injury, not for those who simply have no one left to manage them. It is the worst possible surrogate parent. Unlike the home, the daycare, or the school, the ER is cold, clinical, and entirely without relationship. I can try to be warm, to speak gently, to show patience; I have children of my own. But to the child before me I am not a father, teacher, or protector. I am masked stranger in a uniform, the embodiment of every needle they have ever feared. I am not a trusted adult. I am the jailer. The child is brought to me explicitly for me to control because no one else can or will, and I am not permitted to refuse him. And when words fail, that needle is all I have left to do it.

I am compelled to participate in this heartbreaking act, even though I know that what these children really need is not haloperidol but a parent. But moms and dads cannot be dispensed from Pyxis machines. They cannot be tubed up from the central pharmacy. I cannot phone one in to Walmart.

Almost all of these children have parents, but not parenting. Their mothers and fathers are present in the biological sense but absent in the moral one, absorbed in lives still organized around their own desires rather than the absolute, all-consuming attention that raising a child requires. Their own lives remain their primary focus, and in that vacuum the screen becomes a de facto parent. These children are pacified not by the steady soothing of a parent but by the rapid, ever-changing stimulation of the algorithm, which offers attention without judgment and novelty without limit. It never says no. It never pushes back. It teaches them that desire is met instantly and that the world exists to accommodate their impulses. And when reality refuses to work that way, the child unravels in precisely the manner the system has taught him to, and then is brought to us.

The Screen

Every day, I see toddlers holding iPads like pacifiers, the flickering glow soothing them where a mother’s gaze once did. Parents sit beside them scrolling their own devices, each captive to a different feed. The child learns early that attention can be summoned on demand, but only from machines. Patience, restraint, and empathy, the virtues once taught by relationship, no longer have an opportunity to form.

When that illusion breaks, the child does not rage against the screen. He rages against the real world, which moves too slowly, answers too inconsistently, and demands too much effort. What we diagnose as attention-deficit disorder is often nothing more than the predictable reaction of a brain reared by the internet and now maladapted to life in reality.

Pediatric psychiatry has responded to this crisis not by questioning its cause but by naming its consequences.

The chronically overstimulated are labeled ADHD. The defiant are called oppositional. The isolated are said to have depression. Each diagnosis creates the illusion of understanding and the promise of a cure. It is easier to prescribe a stimulant than to confront a parent.

The child becomes the patient, and the parent becomes the victim of a mysterious disorder beyond his or her control. We turn social failure into medical pathology and congratulate ourselves for our compassion. We feel bad for the parent, burdened with a sick child. What constitutes good parenting no longer means correcting the child’s bad behavior but instead means faithfully attending medical appointments and giving psychoactive medications every morning.

The Parents

The vast majority of these parents are not cruel or neglectful. They are exhausted, anxious, and digitally addicted in their own right. I do not blame them. They are doing what they were taught to do. We live in a society that no longer believes in anything beyond personal fulfillment. The old moral frameworks that once demanded sacrifice for the sake of the next generation have collapsed. Parenthood has been reframed not as a duty to the future but as a path to self-actualization. Children are expected to give meaning to their parents’ lives rather than to receive formation from them. When fulfillment is the goal and not the byproduct, the hard work of shaping a child’s character loses its urgency. Why endure the daily frustrations of discipline and correction when the culture insists that the point of parenthood is not the future but the parent’s own experience of it?

A society that believes in nothing beyond the self cannot produce parents capable of the supreme sacrifice that good parenting requires. It is unsurprising that so many turn to screens, schools, and finally the ER to manage what they were never prepared, encouraged, or taught to bear. The individual parent falters because the culture has already surrendered.

These parents live in the same attention economy that devoured their children, but with one crucial difference: they remember, dimly, what it was like to live without it. Their children do not. For them, silence is terrifying, boredom intolerable, and the absence of stimulation a form of withdrawal.

These children are not broken. They are perfectly adapted to the world we built for them, a world of endless distraction and absent consequence. The tragedy is not that they are sick, but that they are normal.

The Technopharmaceutical Complex

The modern child is both consumer and commodity. Big Tech creates dependence, and Big Pharma monetizes it.

One trains the brain to expect constant novelty; the other sells chemical focus to survive it. We call this “treatment,” though it is closer to market correction. The same culture that destroys attention then offers to rent it back to you at a monthly cost.

The incentives align perfectly. Tech companies profit from overstimulation, and pharmaceutical companies profit from the behavioral fallout. Each sector insists that it is meeting a need, and in a sense it is. But it is a need they helped manufacture. No one asks why every year produces a new cohort of children who cannot sit still, cannot focus, cannot tolerate boredom, and cannot obey even mild authority. We treat the symptoms as though they appeared spontaneously, unrelated to the media diet we feed them from infancy.

Stimulants and sedatives have become the two pillars of childhood. One is given in the morning to induce focus for school. The other is given at night to counteract the first. The child oscillates between chemically sharpened compliance and chemically induced sleep. This is considered success. If the dosage needs to increase, that too is considered success. It is framed as progress because the chart shows improvement, even if the child’s mind does not.

What was once moral failure, such as impulsivity, defiance, or gluttony, has become a subscription model. The digital economy rewards what medicine pathologizes. Between them, they have built a system that calls weakness compassion and sells it by the dose. A child who cannot sit still becomes a revenue stream. A teenager who cannot tolerate silence becomes a market opportunity. A generation that cannot endure discomfort becomes an annuity.

None of these children ever seem to get better. They do not graduate out of their diagnoses. Rather, they accumulate more of them. Their medication lists grow longer. Their sense of agency grows smaller. They enter adulthood already convinced that their own minds are defective and that stability comes only in twelve-hour, extended-release increments, manufactured in a laboratory.

The ER

All of this eventually returns to my doorway. The ER absorbs the consequences of every failed institution, every abdicated responsibility, every cultural lesson that taught a child to expect the world to obey him. By the time they reach me, the damage is already done. There is no medication I can prescribe to reverse a childhood spent in front of a screen, no order set that can create discipline or conscience, no psychiatric admission that can teach patience or empathy. I cannot summon the family, the school, the church, or the community they never had. Most of these children are not orphans, but their loneliness is indistinguishable from orphanhood.

Yet I am the only party in this entire chain who is not permitted to say no.

I cannot refuse the patient. I cannot refuse the problem. I cannot refuse the cycle. I am legally required to participate, even when participation means little more than documenting the same story, admitting the same child, and watching the same pattern repeat.

I perform the ritual because the system demands the ritual, not because it heals. I know that the inpatient stay will not help. I know that the child will not emerge transformed. I know that there will be another tantrum, another outburst, another threat of suicide, each one triggering the same cascade of liability-driven responses that bring him back to me. The cycle is self-perpetuating. The enormous attention given to each crisis does not extinguish the behavior. It reinforces it.

The hopelessness comes not from the chaos of the moment but from the certainty of its return. I stabilize the child in front of me while already seeing the adult he will become. I see the impulsivity hardened into violence, the entitlement calcified into rage, the lack of discipline evolving into danger. One day, I will restrain and sedate that adult not because he is frightened and lost, but because he has truly hurt someone. I see the arc before he does. I see the future before he can imagine it.

The tragedy is that none of this was inevitable. It was taught.

And still the child is brought back to me, again and again, because I am the only one who cannot refuse him. The ER was never meant to raise a generation, yet it has become the last refuge of children abandoned not by parents, but by the culture that shaped them. Until that culture changes, we will remain its digital orphanage, caring for the lonely under fluorescent lights while their phones glow beside them, waiting for someone to finally look up.

One of my earliest encounters with this worldview came long before medicine. In elementary school, my trapper keeper disappeared from my desk. I knew it was stolen. Teachers assumed I was careless or dishonest, manufacturing an excuse rather than accepting responsibility. I was neither. I later found the binder tossed behind lockers, its contents partially destroyed, another child’s name written inside. I brought it to my teacher, vindicated. Nothing happened. No discipline. No acknowledgment of wrongdoing. The lesson was not lost on me. Certain transgressions were excusable depending on who committed them. Whatever the intent, the effect was that accountability yielded to racial discomfort, and misconduct went unaddressed.

That same pattern followed me through every subsequent academic gate. I did not merely have to be competitive. I had to be exceptional. To gain admission to a private high school, I posted one of the highest entrance exam scores in the school’s history, while many minority students were admitted with weaker academic records, subsidized tuition, private tutoring, and broad tolerance for misconduct. This disparity widened rather than narrowed in college and medical school.

By the time I applied to medical school, my résumé would have been regarded as elite had it belonged to a different demographic. A perfect GPA. 99th percentile MCAT. A strong academic pedigree. Yet my acceptances were limited to in-state public schools. The message was implicit but unmistakable. Merit was necessary, but no longer sufficient, and in some cases was actively disfavored.

Medical school stripped away any remaining ambiguity. I served on the admissions committee and saw the process from the inside. Officially, we evaluated applicants on academic performance, personal statements, and interviews. In practice, Black applicants were set aside for special review by the dean of admissions, who personally selected a cohort irrespective of objective qualifications. This was not presented as an exception, but as an explicit institutional commitment.

Once admitted, these students were insulated from the rigor the rest of us faced. They were graded on a different curve. They carried a lighter course load. While the rest of the student body used summers for research or remediation, these students were allowed to stretch preclinical coursework over the additional time. They received extra time on exams and private tutoring unavailable to others. Many still failed to graduate on time. Most were ultimately passed along anyway. These accommodations were not tied to individualized remediation plans or objective performance deficits, but were granted categorically based on group membership.

Residency reproduced the same pattern. Despite women being over-represented in medicine, program leadership openly stated that rank lists would prioritize women and under-represented minorities.1 As chief resident, I interviewed applicants whose board scores and CVs would have disqualified them under any neutral standard, yet they were described as “high flyers.” I could not voice reservations without risking accusations of racism or professionalism violations. Silence was safer.

The outcome was entirely predictable. The residents admitted under these preferences consistently underperformed. The only residents ever held back during my residency training were Black. That fact itself generated accusations of racism, including a graduation boycott. The irony was complete. Those claiming victimhood were the primary beneficiaries of racial preference. Those constrained by it were expected to absorb the consequences quietly.

This inversion is not confined to admissions committees. It now dominates medical research and media interpretation.

A widely publicized study claimed that Black infants experience significantly lower mortality when treated by Black physicians, and that White physicians contribute to racial mortality gaps.2 The story ricocheted through mainstream media, reinforcing a familiar narrative: White doctors are biased, incompetent, or indifferent.3 The original paper was more cautious in its language, but those nuances were discarded in media coverage that framed physician race itself as a causal determinant of infant mortality.

Subsequent reanalysis of the same data revealed a far less ideological conclusion. Once case severity, particularly very low birth weight, was properly controlled for, the purported racial effect largely disappeared. White physicians disproportionately cared for sicker, higher-risk infants and achieved comparable or better outcomes.4

The problem is not that authors and reporters are making honest errors, which overwhelmingly seem to go in the same direction. The problem is motivation and agenda. The medical literature and the press increasingly select for conclusions that affirm racialized moral priors, even when the data do not.

Doctors who challenge this framework learn quickly that dissent carries consequences. The most instructive example is Norman Wang, a cardiologist and academic who published a peer-reviewed critique of DEI policies in cardiology.5 His article questioned the effectiveness and legality of race-based workforce initiatives. It was retracted despite no evidence of fraud or data falsification. He was stripped of leadership roles and marginalized within his institution.6 He later brought civil suit which was ultimately unsuccessful.7 The message to other physicians was clear. Questioning DEI orthodoxy carries professional risk, even when done through peer-reviewed scholarship.

Certain conclusions are impermissible regardless of the quality of evidence supporting them. In academic medicine, disagreement on matters of race and equity is not treated as an intellectual dispute to be resolved through debate or further study, but as a moral transgression requiring correction. Consensus is enforced not by persuasion, but by professional risk: loss of status, loss of authority, and loss of institutional belonging. Within such an environment, self-censorship becomes rational behavior, and conformity masquerades as virtue. In practice, this manifests in admissions meetings, rank list discussions, and curriculum committees where reservations go unspoken and unanimity is mistaken for moral clarity.

DEI has not made medicine fairer. It has made it less honest. It has replaced merit with optics, standards with sensitivities, and truth with narrative management. It has created a class of physicians shielded from accountability and another class taught that silence is the price of survival. Academic medicine and its media partners are active participants in portraying White physicians as moral liabilities and racial minorities as perpetual victims, even when data and lived experience contradict that framing.

The greatest casualty is not professional morale but patient safety. Medical training is not a symbolic exercise or a social credential. It exists to prepare physicians for decisions that carry irreversible consequences, often made under uncertainty and time pressure, where errors are measured in permanent injury or death. When the purpose of training shifts from identifying and developing the most capable physicians to serving as a mechanism for social signaling or retrospective moral repair, merit and competence inevitably lose their primacy. Standards soften, expectations fragment, and ultimately, patients are harmed. If medicine is to remain worthy of public trust, there must be non-negotiable standards of competence that are transparent, uniformly applied, and insulated from political fashion. A system that cannot speak honestly about competence cannot reliably ensure it.

I was raised Catholic. Like many children, I attended CCD, or what some call Sunday School, where parent volunteers did their best to teach the faith. I was an inquisitive and precocious child, more interested in causes than customs, and I suspect I needed a bit more metaphysical detail than they were prepared to give. One day our class discussed the world’s other religions. We learned that Judaism, Islam, Buddhism, Hinduism, and many others each had their own doctrines, their own scriptures, and their own gods. Near the end of the lesson, I asked what seemed the obvious question: Who’s right?

The teacher’s answer startled me. “We don’t know.”

That answer dissolved the ground beneath my feet. If we did not know, then what had all of this been for? The prayers, the readings, the rules? Were we no more certain of our truth than the Hindus were of theirs, all of us guessing in the dark? The question lingered. It lingered all the more as the priest scandals erupted across the Church. My parents, shaken, withdrew from parish life. I was never confirmed. By the time I reached high school, I called myself at times agnostic and at others an outright atheist. I was mostly open to possibility of God, but I did not feel His presence nor did I even know how I would recognize such an experience were I to ever have it.

Medicine has not made faith easier. If anything, it has deepened my doubt. I am surrounded by suffering that mocks any simple notion of divine justice. The innocent die. The wicked are preserved. I have pronounced infants, toddlers, and teenagers dead, and each time it feels like a refutation of Providence. Every day I am steeped in death, but familiarity with mortality has not made me any more comfortable with it. Death is always horrific. The more I see of it, the less natural it seems. I have never found any meaning in it, nor any evidence that there is anything after but the terrifying prospect of oblivion and nothingness.

And yet, the desire to believe lingers.

I still am not given to religious feeling. I admit I am envious of my wife’s recent conversion, the immediacy of her faith and the joy and peace she finds within it. But today, I cannot call myself atheist, and as I age I find disbelief increasingly untenable. These days, I call myself Catholic.

What has helped to persuade me is that I know that objective right and wrong exist. I do not feel this as a matter of opinion; I know it as a fact. My conviction that certain acts are truly evil, not merely inconvenient, is as immediate as my awareness that fire burns. That knowledge is itself evidence of God. If moral truth exists, then there must be a mind for which it is true. A law implies a lawgiver.

To the secular mind, good is what works. Evil is what disrupts. Atheistic morality, when reduced to its essence, is utilitarian and Darwinian. It holds that moral instincts arose because they improved our chances of survival. By this reasoning, honesty is valuable only so long as it produces stability, generosity only so long as it yields reciprocal benefit. The moral sense is explained away as an evolved instinct, useful but not true.

Without God, good and evil dissolve into usefulness and harm. Morality becomes etiquette, adapted for survival. The secular man may still condemn murder, but he condemns it as maladaptive, not as wrong in itself. Murder is bad only as a matter of social evolution; it isn’t good for the tribe to murder one another, which is the secular explanation for why almost all human civilizations have regarded murder as wrong.

Should circumstances change, however, and should murder one day advance the collective, the atheist would have no ground on which to call it evil. If one day it became useful, if it benefitted the tribe, the ideology, the species, it would cease to be evil altogether. Even if an atheist may say that murder is universally wrong, what he means is that social structures and circumstances have not yet arisen under which murder would be palatable or even beneficial. Secular ethics are ultimately always conditional, not categorical.

We have seen this play out in culture. When a man regarded as politically wicked is attacked or killed, there is applause. His death is called justice because it serves the right cause. The act is not evil but useful. This is the logic of a morality without God: sin becomes strategy, and the ends justify the means. Such reasoning is inevitable once moral law is replaced with mere moral feeling.

Believers mean something entirely different when they speak of morality. To say that murder is wrong is not to say it is maladaptive or impolite but that it violates an objective law that exists whether or not it serves us. Right and wrong are not social inventions; they are features of reality. To deny this is to turn morality into arithmetic written in sand, to be erased and rewritten by every tide of circumstance.

The irony is that even the most convinced secularist cannot help but speak as if morality were real. He still uses words like good, better, and just, as if they described real qualities rather than feelings. Environmentalists claim that the earth would be better without humanity. Better for whom? If there is no God and man is a cosmic accident, the planet has no moral trajectory. A green world and a barren one are equally meaningless. To whom would it matter what color is the giant rock hurtling through empty meaningless space? To say that one state is better than another assumes a standard of goodness beyond matter, a cosmic preference that can only belong to a mind. Without such a mind, the language of better and worse is gibberish.

This same confusion pervades medicine. The modern bioethical lexicon is borrowed from the moral tradition that secular medicine has otherwise abandoned. Words like justice, autonomy, altruism, and beneficence once referred to truths grounded in the sacredness of the person. The form endures, but the faith that animated it is gone. Justice presupposes an order of right, and autonomy presupposes that life has worth independent of the collective. Both are remnants of a moral universe built by faith. In the secular hospital they persist but are repeated without belief.

It was not always so. The hospital itself was a religious creation. Monks and nuns tended the sick as acts of charity, following the example of Christ who healed the blind and the crippled, cleansed lepers, and dined with sinners. To care for the sick was to imitate the ministry of Jesus, who made no distinction between the deserving and the undeserving, the pure and the impure. The poor, the deformed, and the contagious were bearers of the divine image. Healing the body was inseparable from caring for the soul. Medicine was a ministry, not an industry.

Today, however, hospitals belong not to the church but to the state. They answer not to God but to government and to the financial mechanisms that stand in His place. Their language has shifted from sanctity to efficiency, from charity to compliance. Their symbols are no longer crosses but logos, their mission statements full of managerial prose. The physician’s duty is measured in outcomes and quality metrics.

This transformation has moral consequences. The modern physician is taught to weigh not sanctity but “quality of life,” a phrase that sounds humane but is, in truth, arbitrary. Who decides whose life is of quality? A ventilator-dependent man with terminal disease may be allowed to die peacefully, and few would call that immoral. Yet when a nation like Canada permits physicians to kill patients who are not dying at all, even those merely depressed or impoverished, it reveals how far the language of compassion can drift without an anchor in the sacred.

The same reasoning governs abortion. The fetus is said to lack quality of life, or to threaten the quality of another’s. The act is justified as mercy, as prudence, as choice. What it is not, any longer, is wrong. A society that ceases to believe in God inevitably ceases to believe in innocence.

Medicine has thus become the most visible experiment in secular morality. It still borrows the language of duty and compassion, but these words are suspended in air. Without God, there is no ground beneath them. When the moral law is untethered from the divine lawgiver, the physician ceases to be a servant of life and becomes an instrument of policy. The white coat, once a vestment, has become a uniform of the state.

I often feel the absence of God in my work. I do not sense His presence in the trauma bay or the ICU. But I cannot accept that the universe is indifferent, because indifference cannot explain the ache I feel when I see a child die or the moral outrage that follows an act of cruelty. These reactions are not evolutionary instincts; they are the soul’s recognition that something sacred has been violated. My inability to believe easily has become, paradoxically, a proof that belief is necessary.

If there is no God, then the human project is meaningless. There is no right or wrong, only cause and effect. The green earth is no better than the barren one, and the healed patient is no better than the dead. But if there is a God, then every heartbeat is sacred, every act of healing a participation in creation itself.

I remain, by temperament, a skeptic. Yet reason itself points toward faith. I believe that life is good, and that belief cannot be sustained without the God who gives it meaning. Medicine may not always remind me of His presence, but it continually reminds me of His necessity.

Medicine, in its hunger for uniformity, has tried to treat them all the same way, with the same vocabulary, the same sympathy, and often the same pills. I have come to believe that there are not one, but three kinds of madness, and confusing them has made psychiatry both omnipotent and impotent at once.

I. The Organic

The first kind of madness is genuine disease, a biological derangement of the mind itself.

These are people I do not doubt are sick in the medical sense. Those who hear voices no one else can hear, who respond to commands from invisible tyrants, who cannot tell whether the person in front of them is friend or figment. Schizophrenia is the purest form, though others belong here as well: mania so violent it shatters sleep and reason, catatonia that stills even the will to eat or move.

These patients are tragic precisely because their suffering is not of their own making. They are, as the old phrase had it, possessed, though not in the supernatural sense but the literal one. Their minds no longer belong to them. I can restrain them, sedate them, protect them from self-destruction, but I cannot call them to account for what they have done. They are not morally responsible, and therefore, paradoxically, they are innocent.

True psychosis is rare, yet it justifies the entire psychiatric enterprise. Without it, psychiatry would have no claim to being medicine at all.

II. The Rational Despair

The second face of madness is harder to categorize because it is not irrational at all. It is despair that has become intolerable.

The man who wants to die after the death of his wife, the woman who cannot bear another round of chemotherapy, the veteran who has seen too much to believe in anything good—these are in my opinion not really diseases of the brain but philosophical crises and rational, existential dread.

We call them “depression,” as though the word itself explained the thing. We prescribe medications based on theorized imbalances of neurotransmitters, yet we make no effort to measure this supposed imbalance when making the diagnosis. What these patients suffer is a deficit not of serotonin but of purpose. They are not wrong to despair; they are right, in a sense too awful to bear. The etiology of this particular disease is found not in the patient’s biology but in his circumstance.

There are forms of grief that should not be medicated. Suffering cannot always be cured with a pill, and to treat it as a chemical imbalance is to trivialize what it means to be human. These are the patients I can speak to honestly, because their pain is intelligible. It is not a disorder, at least not in the same sense as schizophrenia; this kind of despair is a rational albeit maladaptive response to devastating and tragic lives and events.

But medicine cannot tolerate meaning. There is no ICD code for an existential crisis and no electronic medical record has the capacity to prescribe Viktor Frankl and Marcus Aurelius. So it calls their despair “major depressive disorder” and their exhaustion “generalized anxiety.”

III. The Learned Helplessness

The third face of madness is neither organic nor tragic. It is behavioral, learned, and often rewarded. These are the patients who have discovered that weakness can be power. They present as victims but behave as tyrants. They do not want to die; they want the world to accommodate them. They demand crisis housing, transportation vouchers, and endless attention, all under the banner of mental health.

This is not illness. It is a moral failure, reinforced by a system that confuses compassion with indulgence.

I see it daily: criminals offered the choice of jail or hospital, patients who insist they will cut themselves if not given narcotics, those brought in after making flippant threats of suicide in an effort to emotionally manipulate friends, families, and lovers. Their symptoms are real in the sense that all behavior is real, but they are also strategic. They have learned that medicine rewards helplessness.

Not all of it is deception, at least not in the calculated sense. Much of it is simple attention-seeking from the lonely, the alienated, the forgotten. They are chronically isolated people who have exhausted the patience of everyone who once tried to help them. Their self-destructive gestures are not driven by intent to deceive but by a need to be seen, if only for a few hours under fluorescent lights in a hospital gown. They do not want to die so much as to be noticed. They have learned to translate loneliness into the only language we still respond to: psychiatric emergency.

When every misfortune is a disorder, personal responsibility becomes pathology. Psychiatry once sought to make the insane sane; now it seeks to make the irresponsible comfortable.

The Moral Confusion

The tragedy is that all three kinds of patients are mixed together in the same waiting room, triaged by the same staff, and recorded under the same diagnostic codes. We cannot treat them differently because our vocabulary no longer permits it. To draw moral distinctions is now considered cruel. It is safer to call everyone “sick” and to medicate accordingly.

Yet this flattening of human suffering into biochemical disorder has cost us more than language. It has robbed us of discernment. The physician’s art was once to judge, to separate the curable from the incurable, the tragic from the culpable. Today, judgment itself is taboo. We call it “stigma” when it is, in truth, the only way to tell the difference between a patient who needs medicine and one who needs moral correction.

For the ER doctor, this confusion defines our daily work.

We must decide, often within minutes, which kind of madness we are seeing, and yet the chart allows no such distinction. Every decision carries risk, and every mistake carries liability. So we admit, medicate, and document, because it is safer to pretend that all madness is medical.

But deep down, we know it is not.

Psychiatry, in its eagerness to be scientific, seems to have forgotten that the mind is not only a machine but a moral being. It can break, but it can also choose. To deny that choice is to deny humanity itself.

This article is part 2 of a series on psychiatric crises in the emergency department. Find the other articles in the series below:

Part 1 - Heller’s Asylum.

In theory, a patient in psychiatric crisis is supposed to receive evaluation and treatment. In practice, I can do neither. I am not a psychiatrist. I cannot prescribe most psychiatric medications safely without follow-up. I have no long-term relationship; I cannot offer continuity or psychotherapy. I must operate under the assumption that I will never see this patient again, though many do return in the same condition. I am asked to judge risk, not to restore sanity. I determine whether the patient may go home or must be confined, and I do so on the basis of a few minutes of conversation, an absence of context, and an abundance of liability.

Patients arrive expecting expertise. They imagine that “psych eval” implies some technical process, perhaps testing, perhaps the insight of specialists. What they receive is a checklist. Are you hearing voices? Do you want to harm yourself or anyone else? Have you made a plan to do it? Few are the questions that determine whether a person will sleep tonight in their own bed or behind a locked door. I am well aware of the absurdity. Yet this is what psychiatry has become in the age of protocol: an algorithm for human despair.

Psychiatric hospitals rarely evaluate patients themselves before admission. They rely on my clinical description relayed by phone call. I may think someone needs admission, but that decision belongs to the psychiatrist on the other end of the line, and they can decline. Many do, especially for patients who are violent, drug-intoxicated, or otherwise complicated. Those patients remain in the ER for hours, sometimes days, waiting for an inpatient bed that may never materialize. They are too dangerous for one institution, too sick for another, and too unstable for the street. The ER becomes their holding cell, and I, their reluctant jailer.

It is fashionable to speak of a “mental health crisis.” What is less often said is that the crisis is administrative, not medical. Psychiatry has fragmented into a bureaucracy of risk management and reimbursement, while society has dismantled every other institution capable of dealing with madness. The asylum closed, the church retreated, the family disintegrated, and the police are told to deliver the broken remnants to the ER. The doctor becomes the inheritor of everyone else’s failure.

Defensive medicine infects psychiatry just as it infects every other corner of care. The decision to admit or discharge has little to do with whether hospitalization will help and everything to do with risk. The incentives are backwards. We hospitalize not to heal but to shield ourselves from blame. Inpatient psychiatry rarely changes the course of these patients’ lives. Most have cycled through the same wards countless times, emerging no better and often worse; they are more medicated, more dependent, more estranged from the world. The decision to admit is not an act of hope but of surrender, a way to offload liability onto someone else. Meanwhile, the ones who genuinely want help are turned away because they do not meet criteria. In the ER, psychiatry is not about who can be healed, but who can be held.

In the absence of psychiatrists, emergency physicians have become their proxies. We perform psychiatric pseudo-evaluations without the authority or the tools to treat. We make moral and medical judgments with no long-term knowledge of the patient, and then hand them back to a world that will do nothing for them. There is no continuity, no follow-up, no healing relationship. Medicine has been reduced to a series of isolated transactions, each one clinically defensible, and none of them truly therapeutic.

The deeper absurdity is that psychiatry itself no longer believes in sanity. Where medicine once sought to restore order to the mind, it now seeks to affirm delusion. Nowhere is this clearer than in the cultural capitulation to transgender ideology, where the doctor’s role has been reduced to validating the patient’s fantasy and mutilating the body to fit it. A profession once committed to curing psychosis now demands that its practitioners participate in it. The same logic underlies much of modern psychiatry: that affirmation is therapy, that denial of reality is kindness, and that suffering can be cured by redefinition.

To practice emergency medicine is to stand in the ruins of psychiatry. The ER was never meant to absorb the totality of human despair, but it has been made to. It is the only institution that remains open when every other door has closed. Police drop off the disturbed and the violent, and the state hides its failures behind our locked triage doors. We are asked to solve problems that are moral, spiritual, and social, yet we are armed only with sedatives, restraints, and paperwork.

Most of us entered the field believing we could help. We thought that our skill and empathy could make a difference. But over time, the pattern wears us down. We realize that we are not rescuing anyone. We are processing them. The patients return unchanged, the paperwork grows longer, and the illusion of doing good becomes harder to sustain. What remains is the performance of care without the substance of it, a ritual meant to reassure the system that something is being done.

The result is a kind of moral injury, a wound of the conscience rather than the body. To be an emergency physician is to be made responsible for unfixable problems and to pretend each day to believe in solutions we know are false.

The more clearly you see the madness of the system, the more insane you must become to keep working within it. That is why so many of us, over time, become patients of the very system we serve.1 We are asked to shoulder impossible burdens, to fix what cannot be fixed, and to act in contradiction to what we know is true. Eventually that contradiction corrodes the soul. The madness of the system becomes our own.