Essays on the practice and economics of pediatric medicine — what the system actually does to physicians, and what physicians can do about it. Published periodically. Always free to read.
Four essays diagnosed one wound: the people who make medicine's intelligence — physicians and patients — hold no claim on it. The cure is not to stop the machine or to sue it one case at a time. It is to build the creators a stake, out of parts that already exist.
HIPAA does not forbid a physician from obtaining the records of the patients they treated. Custody, a permission no one is required to honor, cost, and a missing design do — while the same record's de-identified twin is licensed for profit.
Microsoft's chief executive has argued that using AI means paying twice — once in money, once in the knowledge you must surrender to make it work. He is right. In medicine, the people who surrender the knowledge are not the ones who signed the contract.
The scribe records the visit to draft the note. But the conversation it captures — your patient's words, your reasoning spoken aloud — has a second life the pitch never mentions: once it is de-identified, it leaves the privacy law entirely, and can train a model the vendor owns.
AI scribes were sold to physicians as relief from the keyboard. The relief is real — but the value those saved minutes unlock is booked by the institution as revenue, while the physician signs the note and holds the risk.
Five essays diagnosed the same wound: the physician cannot see what the work is worth. The cure is not a better number — it is a number the physician can see, and owns.
Medicaid spending on care has ballooned and pediatric pay has not. The money is real — it is routed through a financing machine, built in plain sight, that lodges it almost everywhere except the bedside.
In every other market, scarcity raises the price. In physician subspecialty labor it lowers it — and the reason is not a paradox but a name economists already have for it.
Pediatric pay is capped not by the value of the work but by the price of the payer — and where the system patches that gap, it routes the correction through channels the physician is never shown.
The country does not lack pediatricians. It lacks pediatricians in the places and on the payers that the economics cannot support — and calling that a workforce shortage points the remedy in exactly the wrong direction.
How the compensation data shaping pediatric pay is produced, who pays for it, and whose constituency it is designed to serve.
Why we're publishing in long form, and what readers can expect.