Monday mornings feel heavy sometimes. A certain amount of that's normal. But I think it's easy in medicine to lose sight of something underneath that heaviness — the privilege we actually have. Not to hit a certain number of visits, or generate a certain number of RVUs, or complete a certain number of procedures. To care for individual humans. Daughters. Sons. Mothers. Fathers. We get to meet them in a time of need. I'm saying this as much to remind myself as anyone reading this. See today as...
9 days ago • 1 min read
I told a story this week that's very personal to me, one I actually tell pretty regularly. Eight months out of residency — good colleagues, work I loved, using my Spanish every day with patients — and I was still burned out. Charts on the couch every night, before my wife and I even had kids. She's the one who finally said, "Something has to change." What actually helped wasn't just working less, though that was part of it. It was rebuilding the workflows underneath — charting in the room...
11 days ago • 1 min read
A colleague of mine — she sees adults, been doing primary care for a long time — told me something last week that's stuck with me. Her practice is scheduled out nine months right now. Nine months. She's wondering how she's even supposed to take care of her patients and see them back when they actually need to be seen. Here's the thing — she knows what good care looks like. She wants to give it. But the way things are currently built, the templates, the panel sizes, the choices made above her...
16 days ago • 1 min read
This week I wrote about the long game. About why endurance runs out and architecture holds. About the three structural decisions that have the most leverage across a career. About what I'm actually building toward at year twenty — and why naming it matters. About the one sentence that holds everything I've written for the past three months: structure protects what willpower cannot sustain. If you've been reading these emails for weeks — opening them, nodding at them, forwarding them...
2 months ago • 1 min read
I've been writing these emails for three months now. Different topics every week — spillover and containment, decision closure and cognitive residue, mid-career weight and presence and warning signs and documentation design and inbox structure and leadership culture and the long game. All of it comes down to one sentence. Structure protects what willpower cannot sustain. Willpower is real. Dedication is real. The internal commitment most physicians carry to doing this work well is real and...
2 months ago • 1 min read
I want to try something different today. I want to tell you what I'm actually building toward — not as an aspiration, but as a structural target that shapes the decisions I make now. At year twenty, I want to still be curious about my patients. Not performing curiosity — actually interested in the people who walk into the room, still finding the work engaging rather than something to get through. I take that as a leading indicator of whether the structure is working. When curiosity is...
2 months ago • 1 min read
If I had to distill the structural work into the decisions that have the most long-term leverage, these three come up most consistently. 1. Decide what the work stops. Not vaguely — specifically. What time does clinical documentation stop? What triggers the transition out of clinical mode? A career-length practice of work stopping at a defined point, with exceptions rather than the exception being that it stops at all, changes the cumulative load dramatically over ten or twenty years. The...
2 months ago • 1 min read
There's a version of a medical career that runs on endurance. Push through training. Push through early practice. Push through the years when the panel is full and the systems are new and the administrative load is still being figured out. Keep going. The assumption, usually unstated, is that at some point it gets easier — that experience brings efficiency, that efficiency brings relief, that relief is what sustainability looks like. Some physicians find a version of that. Many don't. The...
2 months ago • 1 min read
This week I wrote about physician leadership and structure. About why your mood is your team's weather — not as a metaphor but as a structural reality. About the single move that has the most leverage for physician leaders: building and visibly maintaining your own containment. About the moment I understood that what I was modeling was setting a baseline for people around me who hadn't been asked about it. About why leaders who model overload normalize it — and what the alternative actually...
2 months ago • 1 min read