The Why Question, Part 1: The Doctor Behind My Why

My why began in illness and healing

Before I could explain it, a sickly childhood taught me this about good doctors: They make you feel better before you actually start getting better. Years later, Simon Sinek's "Start With Why" gave the lesson a name. This post walks through Simon Sinek's Golden Circle — Why, How, What — and pairs it with Daniel Pink's research on purpose, autonomy and mastery as drivers of motivation. It includes a short exercise to find your own Why, a candid admission that this blog’s Why only became clear to the author a year into writing it, and a bedside technique borrowed from addiction medicine: asking a patient why they want to change instead of telling them why they should.

  • 6 mins

The Why You Never Said Aloud

Margin mission

As a debate rages over whether business schools should close, physicians already know where purpose comes from. Medicine instills the Why. What nobody teaches is how to say it. Through the story of a residency faculty member who pushed trainees to see patients faster with no reason beyond “that’s real life,” this post shows what fills that silence, and offers one fix: the “Because” Test.

  • 7 mins

The Standardization Tax, Part 4: Who Pays It and How

Someone will pay The Standardization Tax

A terminal cancer patient, offered a copay-free MRI, declines it. Instead, she chooses to keep her MRI at the hospital where all her doctors are. That decision anchors The Standardization Tax series' final argument: when a load-bearing wall comes down, someone pays for it. Physicians absorb unpaid time for conversations and documentation that the schedule doesn't allow. Patients absorb the cost of fragmented knowledge or flattened preferences. The post closes with practical advice on scope rather than sacrifice, and a direct, honest answer to the pre-med student who opened the series.

  • 8 mins

The Standardization Tax, Part 3: The Two Load-bearing Walls

Standardization and handoffs lead to knowledge lost

Post 2 in the series was about doubting your own judgment and attention enough to follow a checklist. This post is about doubting it enough to ask the patient what they want, and to trust knowledge you didn't personally build. It covers two kinds of load-bearing variation: the wall built by patient choice (Wennberg's preference-sensitive care and the shared decision-making it requires) and the wall built by a physician's earned knowledge of a patient over time, i.e., continuity of care. Standardizing either wall away doesn't reduce waste. It reduces choice or erases knowledge whose value nobody understood until it was gone.

  • 9 mins

The Standardization Tax, Part 2: Why We Need Standardization

standardization can be an important tool to reduce errors

Before The Standardization Tax series argues against a certain kind of standardization, this post gives standardization its due. It opens with the true story of a five-step checklist Dr. Peter Pronovost developed at Johns Hopkins, which cut central-line infections in Michigan ICUs by 66 percent and saved thousands of lives. That success came from eliminating plain human error, not judgment. The post then turns personal: learning, during psychiatric training in the U.S., to ask every patient about alcohol and drug use as routine rather than a judgment call — and years later, watching another psychiatrist skip that same question during a mock board exam, for reasons which reflect the author's own earlier blind spot. The line is clear: variability in care can come from mistakes. And if standardization can eliminate those mistakes, then we should go for it.

  • 6 mins

The Standardization Tax: Not Every Tradeoff Is Worth It

continuity of care is a given in rural medicine

What would a pre-med student think if she heard how many doctors today say that they would steer their own kids away from medicine? They blame increasing corporatization, shrinking autonomy, and burgeoning documentation burden. These stem from increasing standardization in medicine. This post, the first in a series, introduces the idea that while standardization has benefits — catching errors, controlling costs, protecting clinician time — it also has a cost. Not all eliminated variation is waste.

  • 6 mins