Category Archives: Colt’s Corner

History of Pulmonary Medicine: From Antiquity to AI

history of pulmonary medicine shows evolution and AI


The history of pulmonary medicine is replete with famous names and milestone events that changed the face of medical science over centuries. From early empirical observations in ancient civilizations to Egyptian texts describing herbal treatments and surgical interventions, it is clear that humanity has suffered from lung disease since the days when Homo sapiens and its predecessors first walked the earth. What follows is not a comprehensive history, but some thoughts on how shifts in knowledge have shaped pulmonary medicine. 

Hippocrates and other Greek practitioners set guidelines for medical practice. They also defined and described many breathing disorders, not the least of which was phthisis, later known as consumption or pulmonary tuberculosis. They described and treated pleurisy and raised awareness about the potential contagiousness of what would ultimately be recognized as infectious lung diseases centuries before the discovery of germ theory.

After that, another Greek physician, Galen of Pergamon, who practiced in the Roman Empire in the second century CE, shaped the future of medicine for centuries. Although many of his findings rooted in anatomical studies and theoretical iterations of what ultimately became the humoral theory for disease needed to be revised or debunked, Galen was forward-thinking in the ways he tied symptomatology (medical semiology), the anatomical structure of the human body, and the external environment on the course of disease. He was among the first to suggest that air, water, and even emotional disturbances could have an adverse impact on human health and wellness.

New theories of medicine prospered only centuries later, when the Islamic physician Avicenna (Ibn Sina) published his Canon of Medicine and Book of Healing (11th century). The Renaissance, however, brought about some of the greatest changes and the abandonment of most antiquated Galenic theories regarding lung disorders. Anatomists/physicians such as Vesalius, who described the mechanics of respiration and demonstrated the principles underlying positive-pressure ventilation, and Michael Servetus, among the first to describe the pulmonary circulation (early to mid-16th century), were instrumental in building new foundations from which future discoveries in pulmonary medicine would be made.

From the 17th to the 20th century, new breakthroughs would occur particularly in the realms of microbiology, pharmacology, imaging studies, and physician concerns for public health. The discovery of oxygen and the physiology of respiration, accompanied by widespread adoption of Laennec’s stethoscope revolutionized bedside diagnosis and global thinking about the diagnosis, treatment, and prevention of pulmonary diseases. 

Concomitantly, advances in the diagnosis and management of infectious lung disease, the establishment of links between smoking and disorders such as lung cancer and COPD, and growing attention to occupational lung disease anchored pulmonary medicine as a social discipline.

Today, we have reached a new inflection point in the history of pulmonary medicine. Artificial intelligence is reshaping medical diagnosis and decision-making in ways that we cannot yet fully comprehend. Machine-learning algorithms already outperform traditional methods in image interpretation for lung nodules and interstitial lung disease. AI-assisted pathology and cytology promise laboratory expertise in even the most remote corners of the world. Tools combining large language models with genomic and gene-editing processes are accelerating discovery and assisting in earlier diagnosis and management of genetic disorders. Robotics and robotic-assisted bronchoscopy are penetrating the pulmonary procedures world at almost warp speed, providing higher diagnostic yields for lung cancer and other disorders by enabling better access to hard-to-reach peripheral nodules compared to traditional methods.

In the face of such rapidly changing times, our challenge is in finding ways to both embrace and harness computational power. While debates about the risks versus the advantages of AI in pulmonary medicine are helpful, we should also focus on how technological authority can go hand-in-hand with professional responsibility.

  • The Cambridge History of Medicine (2006). Eds. Roy Porter. Cambridge University Press.
  • Murray JF. A thousand years of pulmonary medicine: good news and bad. European Respiratory Journal 2001 17(3): 558-565; DOI: https://doi.org/10.1183/09031936.01.17305580.
  • Mahajan AK, Duong DK, Cortes J, et al. The Match 2 Study: Robotic Assisted Bronchoscopy with Integrated Imaging with Assessment of Digital Tomosynthesis (DT) and Augmented Fluoroscopy (AF): Three-Dimensional Accuracy as Confirmed by Cone Beam Computed Tomography (CBCT), Respiratory Medicine 2026. https://doi.org/10.1016/j.rmed.2026.108693.
  • Topol EJ. High-performance medicine: the convergence of human and artificial intelligence. Nat Med 2019;25(1): 44-56. 

If you like what you read, please follow me and subscribe to the The Art of Being Human on SUBSTACK

A New Home for My Writing

landscape stethoscope and ink pen announcement of new home for Henri Colt on Substack


I’m grateful you have been reading my work here, and I’m honored that so many of you around the world have viewed or downloaded educational materials from bronchoscopy.org in support of our shared educational mission.

I will continue to add to this website, and to post on Colt’s Corner.

For some time now, however, I’ve been thinking about where my longer, more reflective writing belongs. These include excerpts from my books, longer essays, short stories, and commentaries—reflections on medicine, philosophy, literature, science, art, and the fragile beauty of our shared lives.

I’ve begun publishing this work on Substack — a quieter space that allows for long-form writing and more direct conversation with readers. 

If you would like to continue reading there, 
you can find my work and subscribe here:
Subscribe on Substack

A recent essay:  On Friendship and Sudden Loss

Communication in Health Care: Patients and Providers

Effective communication in healthcare

 Communication in health care relies on a foundation of trust and psychological safety amid unexamined assumptions, non-dits (which is French for things left unsaid), potentially mismatched expectations, asymmetries of knowledge and power, vulnerability, unspoken emotional defenses, and differences in understanding or health care literacy. Perhaps this is why effective communication requires more than clarity of language. It also requires our attention to meaning, context, and subjective experiences, including the “emotional baggage” carried by all those involved in our conversations.

Whenever we communicate, we receive, transmit, and interpret both information and feelings. Psychological research shows that effective communication in health care is tied to perceived empathy, narrative coherence, and opportunities for all involved parties to be heard. Taking the time to sit at the patient’s bedside and avoiding potential distractions such as phone calls, computer screens, or unnecessary interruptions can be key to establishing rapport. In my experience, providers operating under time constraints, emotional strain, or institutional pressures have difficulty recognizing how fear, hope, and struggles tackling ambiguity or uncertainty adversely affect their patients’ understanding. They risk using technical jargon, matter-of-fact approaches, or paternalistic attitudes to rush through a conversation, disregard differences in health care literacy, or achieve a specific desired outcome. Hence, health care providers might subconsciously or intentionally distance themselves emotionally from their patients. The result is a potential undermining of a patient’s trust. Consequently, both caring and compassion are sacrificed on the altar of efficiency.  

Interprofessional communication between physicians, nurses, technicians, and allied health professionals also has its challenges. Healthy dialogue means overcoming real and perceived hierarchical barriers and role ambiguities. It means negotiating intergenerational differences, acknowledging differing professional identities grounded in diverse yet strangely singular training paradigms, and recognizing inward disengagement even when outward appearances signal agreement or a willingness to comply.

Overall, this introduces yet another layer of complexity to effective communication. Cultural expectations can vary significantly among trainees, mid-career professionals, and more senior practitioners. Intergenerational differences of opinion might exist regarding what constitutes competence and professionalism, for example, or how to communicate with respect to cultural diversity. Not everyone has similar views on the appropriateness of multitasking (it took me a while to realize that young people can remember and reflect on what I say even while scrolling through pictures and texts on their mobile phones), or on when to rely on narrative versus factual reasoning. 

Much more can be said about communication in health care. In future essays, I will briefly address dialogue between health care providers and administrators, conversations with patients’ families, and the challenge of effective communication with staff, other team members, and direct reports. I will also discuss communication failures and why I believe the observation and improvement of communication skills should be an integral part of competency—based training.  

Maleficence in Healthcare

Shows doctors and examples of intentional and unintentional maleficence


Maleficence in healthcare refers to any intentional and unintentional harm caused by healthcare providers or health systems. It is usually discussed in contrast to nonmaleficence, the avoidance of causing harm, one of the pillars of the Four Principles approach to medical ethics proposed by Beauchamp and Childress in the 1970s.

Intentional maleficence manifests as deliberate actions that knowingly harm patients. Thankfully, it is rare, and acts of intentional hurt, deception, exploitation, or fraud are universally frowned upon by health care providers, professional organizations, institutions, and society at large. Any intentional infliction of harm obviously betrays patient trust, which is the foundation of all physician-patient relationships.

Some of the most notorious examples of intentional maleficence stem from authoritarian regimes or times of military conflict. Acts ascribed to Nazi healthcare providers before and during World War II are among those most frequently cited. Forced euthanasia, the deliberate killing of populations considered unworthy of life, forced sterilization programs, and harmful experimentation in the name of science (such as cold-water immersion, intentional injection, or exposure to knowingly toxic substances, etc.) illustrate how Nazi doctors, midwives, nurses, and technicians intentionally murdered, tortured, or abused patients and other victims of the repressive Nazi regime. 

Other flagrant examples of intentional maleficence occurred during Argentina’s brutal military dictatorship (1976-1983). During this time, some health care providers were complicit in the torture or murder of innocent victims detained by state agents. This included documenting false causes of death (such as falls from high places), administering drugs to torture victims, and falsifying records used to facilitate unlawful adoptions of disappeared children. 

Equally disturbing are discoveries made during and after the Second Gulf War (2003-2011). Health care providers pressured by Saddam Hussein’s oppressive Ba’ath regime allegedly falsified death certificates and misrepresented legal reports of torture. Also troubling are reports that psychologists and United States military personnel failed to report human rights abuses of detainees undergoing interrogations at Abu Ghraib and Guantanamo Bay. 

Of course, cases of intentional maleficence are not limited to health care delivery under authoritarian or military regimes. Other examples include unethical human experimentation, the deliberate withholding of treatment (the 40-year Untreated Syphilis Study at Tuskegee comes to mind), performing unnecessary procedures regardless of context, economic misconduct and fraudulent practices to satisfy scientific, personal, or financial ambitions, and ideologically-driven care that disregards patient welfare in favor of personal gain or adherence to doctrinal beliefs and political policies.

*

While intentional maleficence is a clear violation of professional ethics and fiduciary duty, the picture is less clear in cases of unintentional maleficence, which is both more prevalent and ethically complex. Unintentional maleficence usually stems from cognitive and experiential bias, system pressures, fragmented care, miscommunication, a propensity to practice medicine defensively, clinical uncertainty, or unwarranted therapeutic zeal. It can also be an unfortunate and even deadly result of medical error, negligence or professional incompetence.

Unintentional maleficence often occurs despite well-intentioned practices. In these cases, ethical analysis is challenging because health care providers usually act in the pursuit of beneficence. A prime example is any medical intervention for which possibilities for an undesired outcome are underestimated or not revealed. High-risk treatments, polypharmacy in vulnerable populations, and technically correct but ethically damaging decisions are other instances where harm may occur despite a health care provider’s intention to help. A well-known illustration is “the double effect,” in which a medical intervention has two causally independent outcomes: one that is ethically and legally acceptable, such as the relief of pain or anxiety, and another that is not, such as a patient’s death from oversedation.

Maleficence in healthcare includes both intentional and unintentional harm caused by clinicians or systems, raising complex ethical challenges that go beyond nonmaleficence. In my opinion, more conversations about these topics are warranted within the Interventional Pulmonology community. This is because maleficence encompasses both intentional and unintentional harms arising from clinical actions, flawed decision-making, or omission. These may result in ethical violations, poor patient outcomes, and ideological harm. Health care providers, institutions, and professional societies are morally accountable to design systems that minimize foreseeable harm and respond proactively to sentinel events. They should create and support conditions that prioritize patient safety, transparency, overall well-being, and ethical awareness over convenience, personal gain, or professional protectionism.

  • Beauchamp TL and Childress JF (2019). Principles of Biomedical Ethics (8th ed). Oxford University Press.
  • Beecher HK. Ethics and Clinical Research. N Engl J Med 1966;274:1354-1360.
  • Weindling PJ (2004). Nazi Medicine and Nuremberg Trials. Palgrave Macmillan.
  • Reis C, Ahmed AT, Amowitz LL, et al. Physician Participation in Human Rights Abuses in Southern Iraq. JAMA. 2004;291(12):1480–1486. doi:10.1001/jama.291.12.1480.
  • Scheper-Hughes, N. The Ghosts of Montes de Oca: Buried Subtext of Argentina’s Dirty War.” The Americas2015;72(2):187-220. Project MUSE, https://muse.jhu.edu/article/579738.
  • Newly unredacted report confirms psychologists supported illegal interrogations in Iraq and Afghanistan. ACLU Release, April 30, 2008. https://www.aclu.org/press-releases/newly-unredacted-report-confirms-psychologists-supported-illegal-interrogations-iraq.

The Ethics of Truth-Telling in Procedural Medicine

Ethics of truth-telling shows patient asking about the doctor's experience.


In this first essay of the new year, I thought I would dedicate a few paragraphs to the ethics of truth-telling in procedural medicine. From the time they are medical students, doctors are burdened by decisions of what to say and how much to share with patients. The range of topics for which these decisions apply is extensive. These extend from revealing the extent of one’s own experience to discussing complications, obtaining valid informed consent, revealing medical error, and sharing diagnostic findings, prognosis, and the likelihood of cure or treatment failure.

The ethical space truth-telling occupies in procedural medicine is especially complex because physicians often find themselves incorporating infrequently practiced or newly learned procedures into their interventional practices. From the time one performs their first blood draw or lumbar puncture to one’s first attempts to perform a complex airway procedure, the questions are the same. How should physicians answer their patients’ queries regarding the extent of their experience? What must they share about the extent of their patient’s disease and diagnosis? What do they say (and to whom) if something goes wrong? How and when do they involve their patients’ family members, and how much personal opinion versus facts should they share about presumptive diagnoses and prognosis?

It is no surprise that the ethical obligation to tell the truth: to disclose risks, alternatives, limitations, and uncertainties, remains foundational in virtually every medical cultural environment. In this sense, truth-telling is not only legally required but also a moral obligation rooted in the ethical principle of respect for autonomy and the preservation of human dignity.

The devil, of course, is in the details. For example, is a doctor’s failure to tell a patient this is their “first time performing the procedure independently” any different from exaggerating about their level of experience? Is a physician’s desire to simplify, soften, or selectively emphasize certain information a form of coercion, a benevolent attempt to reduce anxiety and facilitate consent, or a subconscious effort to frame discussions in ways that conform with institutional norms or personal goals and values that might differ from those of their patients? 

From an ethics perspective of justice, truth-telling in procedural medicine cannot be separated from notions of equity, power, and access to understanding. Patients do not enter procedural encounters on equal footing with their health care providers. They are not only at a disadvantage due to illness-induced vulnerabilities. They are also affected by disparities in health education, socio-economic status, language fluency, healthcare literacy, and cultural biases regarding whether and how to question a physician’s experience and authority. To complicate matters further, procedural risks are probabilistic and often context-dependent. The ethical weight of truthful disclosure in these settings is therefore especially pronounced.

Many other aspects of care related to telling the truth warrant discussion. In this short essay, I simply suggest that truth-telling in procedural medicine occupies a central place surrounded by the triumvirate of clinical uncertainty, technical expertise, and patient vulnerability. Physicians who navigate these unsteady waters can be guided, however, by their personal integrity, a profound respect for their patients’ moral agency, and a steady commitment to medical professionalism regardless of institutional and societal pressures.

  • Beauchamp TL and Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford University Press, 2019.
  • O’ Neill O. Autonomy and Trust in Bioethics. Cambridge University Press, 2002.
  • Sheldon M. Truth-telling in medicine. JAMA. 1982 Feb 5;247(5):651-4. PMID: 7054566.

Beneficence, Benevolence, and the Act of Doing Good

Woman holding heart benevolently to elderly woman with cane. Benevolence and good intentions


More than two thousand years ago, the Hippocratic Corpus (5th century BCE) fostered principles of beneficence, non-maleficence, confidentiality, and accountability to help guide physician practices and behaviors. These ideals were later embraced by Christian, Jewish, and Islamic ethical traditions from the Middle Ages through the Enlightenment. In 7th century China, Sun Simiao emphasized compassion, selfless dedication, and duty in his important work, On the Absolute Sincerity of Great Physicians, while Buddhist traditions, coexisting with ancient Confucianism, valued generosity (dāna) and the precept of non-injury. Across cultures and eras, medical ethics has thus joined duty with virtue, blending obligation and character to help define good medical practice.  

In contemporary healthcare ethics, beneficence is described as actions and rules aimed at benefiting others, helping them further their legitimate interests and preventing or removing potential harms. It is usually viewed as a moral obligation or duty rooted in professional responsibility. It defines what one ought to do in a particular situation, whether to improve patient welfare, protect life, or pursue specifically desired health-related outcomes.

Benevolence, by contrast, describes a disposition, not an obligation. The Oxford Dictionary of Philosophy defines it as the “general desire for the good of others, and a disposition to act so as to further that good.” While benevolence derives from the principle of beneficence, it is a moral virtue equated with charity, kindness, and generosity. As such, it can be distinguished from beneficence in that it is grounded in goodwill toward patients rather than in professional duty. While beneficence concerns right action, benevolence concerns right intention—and the two, though often aligned, are not identical.

This distinction becomes evident in clinical practice. For example, a physician may act beneficently toward a patient because of their sense of duty, even when the patient is abusive, dangerous, or requesting medical aid in situations that conflict with the physician’s personal values. In such cases, a doctor’s intrinsic desire “to do good” for their patient may be lacking, yet they may still act rightly and in accordance with professional standards. 

Benevolence, however, explains actions of a different type. Grounded in the humanity of health care providers, it reflects a physician’s disposition toward goodwill rather than obligation. It may motivate behaviors that are ultimately detrimental to a patient’s well-being when unchecked by professional or ethical norms. It may also explain why some providers undertake actions that are heroic or go beyond those required by duty. In the extreme, these may involve extraordinary personal sacrifice to aid vulnerable patients. 

In the end, the practice of medicine is judged not only by outcomes and rules, but by intention. Beneficence may compel right action in the right circumstances, while benevolence often reveals the moral character—the right reasons—from which care emerges. Together, they affirm essential moral dimensions of ethical medical practice.

Why World AIDS Day Still Matters

Doctor in white coat wearing the Red Ribbon that remains a symbol of awareness, compassion, and the unfinished work of ending AIDS.
Photo courtesy Bermix studio (Unsplash)

HIV/AIDS is now manageable, yet millions of people still lack access to care. The world commemorates December 1 as World AIDS Day, a date observed since 1988 to remind us that HIV/AIDS remains a major global health challenge. Today, more than 40 million people are living with HIV worldwide, the majority in sub-Saharan Africa. Thanks to antiretroviral therapy and improved treatment of opportunistic infections, deaths from HIV/AIDS have fallen by more than fifty percent since 2010, and HIV can now be considered a chronic, manageable health condition. 

Transmission of HIV continues, however. More than one million new infections occurred in 2024, with particularly high rates among young women in Africa. Moreover, according to the World Health Organization, only 87 percent of people living with HIV know their status, and nearly one quarter are not receiving antiretroviral therapy.

Yet political commitment has not translated into equitable access. In 2015, United Nations world leaders unanimously pledged to end the AIDS epidemic by 2030. According to UNAIDS, the world is not on track to meet that goal. Progress has been hampered by breaks in solidarity between and within countries. Advances in long-acting treatment and prevention technologies are not being adequately shared with all low- and middle-income nations, and many HIV programs continue to overlook people from key populations. These include sex workers; gay men and other men who have sex with men; people who inject drugs; transgender people; and people who are incarcerated or detained in closed settings. At the same time, rising infection rates are being reported in eastern Europe and central Asia, Latin America, and the Middle East and North Africa. 

Although access to HIV treatment continues to expand, prevention and education programs have suffered from chronic underfunding. Household surveys suggest that condom use has declined in recent years, particularly among young people aged 15-24 and among those engaging in sex with non-regular partners. In many countries, community-led organizations are also struggling to survive financially, especially those addressing HIV alongside broader human rights concerns, including the right to universal health care.

Given that millions of people continue to live with HIV infection and HIV-related disease, HIV/AIDS remains a serious threat to public health. Continued progress in prevention, diagnosis, and treatment is essential, but at least three additional challenges demand attention. First, stigma and discrimination must still be eliminated in many regions. Second, the aging population of people living with HIV requires health systems capable of managing patients with chronic comorbidities such as hypertension, diabetes, and cancer. Finally, health care providers and community educators must not overlook the ongoing risk of HIV transmission among older adults.

The awareness ribbon reminds us that awareness without action is insufficient. The never- trademarked Red Ribbon was chosen as the international symbol of AIDS awareness by the Visual AIDS Artists Caucus in 1991 and was first worn by actor Jeremy Irons at that year’s Tony Awards. The ribbon symbolizes love and compassion for those people living with HIV/AIDS, blood in recognition of transmission, and urgency—a signal that the work of prevention, solidarity, and care remains unfinished.

The Revolutionary Spirit in Medical Education

Shows physician signaling a the digital democratization revolution in medical education to a student at the computer


In her book, On Revolution, German-American political thinker and philosopher Hannah Arendt (1906-1975) wrote that a revolutionary spirit is not defined as the action of a people, but as a set of political principles characterized by concomitant ideas of freedom and the experience of a new beginning. For medical educators, the concept of the democratization of knowledge, associated with the proliferation of computers and web-based learning, interactive information systems, and greater access to virtual reality and computer simulation, embodies such a revolutionary spirit.

This is because the widespread dissemination of educational systems dedicated to the health care environment is the exact opposite of the antiquated practice of coerced acceptance of information through conventional power structures in the ivory towers of academia. The older system was often based on academic hierarchies and teachers who, as both owners and retainers of knowledge, had power over learners. The newer system, however, is built on the give-and-take of democratization, with virtually instantaneous, open access to information enabled by affordable technological advances. These include but are not limited to critical analyses of that information through podcasts and interviews, open access rather than fire-walled peer-reviewed scientific literature, and thousands of lectures or commentaries on YouTube and other social media sites.

Arendt also wrote that revolution implies a change radical enough to be experienced as an entirely new beginning. It signifies more than a change, which, as Arendt says, can be cyclical (as in change from one form of government to another; a monarchy might become an oligarchy, an oligarchy might become a democracy, and so on). A revolution is also not to be confused with rebellion, which might substitute one form of leadership, or one prevailing paradigm, for another. Nor is revolution, in its social and political sense, a restoration to what once was. In other words, it is not represented by coming full circle back to a preordained order.

Instead, a revolution, according to Arendt, signifies a new beginning, not only in social thought but also regarding actions inspired by a “revolutionary spirit.” In his brilliant new series titled The American Revolution, documentary filmmaker Ken Burns illustrates how the American colonies’ revolt against Great Britain was inspired by such a spirit fueled by the novel idea that all men had inalienable political rights by birth. Of course, there were shortcomings to the founding fathers’ implementation of this idea, for sadly, it would take many years before such “rights” would be extended to indigenous populations, enslaved people, and women.

But the purpose of this essay is not to expound on the concept of revolution, but to reflect on whether medical education today represents the dawn of a new beginning marked by digital democratization and driven by the revolutionary spirit. I believe it is, although with some caveats. 

Technology allows for information, ideas, and images to transcend national boundaries. Still, healthcare professionals benefit greatly when they personally identify with physical role models and engage in the intricacies of the human experience gained through direct, face-to-face interactions with their patients. Just as a teacher’s actions and behaviors influence their students’ manners and performances at the bedside, for example, a patient’s feelings and behaviors can equally affect the ultimate quality of a physician’s professional attitudes and demeanor.

We must not forget, therefore, that health care delivery entails the delivery of healthcare, which is, after all, a human service profession. Learning to care for the sick, the injured, and the fatally ill with demonstrable empathy and compassion is not easily mastered through books and modern technology alone. The revolutionary spirit might spark our embrace of new technologies and educational systems but carries in its mist all that is valuable and sacred about the physician-patient encounter.

California’s Care Divide

Doctors provide care to low-income patients


California’s health care system is increasingly divided between two contrasting health care business systems. These are high-cost concierge medicine and the essential safety net of Medi-Cal. This growing split is shaping health care experiences across the state. It is not surprising, therefore, that many of my friends and acquaintances have been complaining about their health care recently. 

Escalating costs, decreased face time with their physicians, obviously hurrying nurses and administrative staff, and difficulties scheduling tests and follow-up appointments are commonly discussed over coffee. Stories of bad experiences seem to abound. One was about a doctor saying they could move their patient through the system faster if they signed up for her ‘concierge services.’ Another was about a subspecialist who didn’t introduce themselves to new patients at a busy neighborhood public health clinic.

This got me thinking again about two aspects of the health care business in the United States, particularly in California, which has a population of almost 40 million. The first is known as Concierge medicine. In these practices, physicians charge substantial monthly or annual retainers, sometimes reaching as high as $20,000 per year. 

These services promise faster access, longer visits, and more personalized care. Some concierge practices bill insurance companies, especially for specialty services, lab tests, procedures, and imaging studies. Others, mainly in the realm of direct primary care (DPC), might not bill third-party insurers for some things. Patients pay either through their retainer or directly using a lower fee-for-service model.

Today, concierge services are provided by about 2% of U.S. physicians, but they are growing rapidly. Some studies show that these services reduce emergency department use and improve patient and physician satisfaction. One recent study showed that California, with its many wealth-concentrated urban and suburban neighborhoods, has the highest concentration and growth rate of concierge practices in the United States. Perhaps this is why people refer to them as “boutique” or “VIP” medicine.

A second aspect of the health care business is Medi-Cal, California’s Medicaid program that provides health insurance to low-income individuals and families. Eligibility is linked to the Federal Poverty Level. This corresponds to about fifteen million people, more than one-third of the state’s residents. According to the California Health Care Foundation, this means 3 in 7 children, 2 in 9 non-elderly adults, and 2 in 5 people with disabilities. It also includes 1.5 million Californians aged 65 and older (about 25% of the 6 million seniors living in California).

My own experience caring for patients with Medi-Cal coverage was, for the most part, nontraumatic. Perhaps this is because my department was in an academic center of the University of California, which did not distinguish between types of insurance. My team considered all our patients VIPs, regardless of insurance status, race, nationality, gender, social position, financial situation, sexual orientation, or education. For this, I am both grateful and proud.

Some criticisms of the Medi-Cal system, however, are long waits for appointments, the high administrative burdens of enrollment and eligibility, and patients feeling discriminated against because of cultural sensitivities, language barriers, and the stigma of their Medi-Cal status and financial conditions.

Thinking about these two contrasting health care business systems reminds me of the complexity of the health care delivery process. It makes me thankful that most of the health care providers I have known, from world-famous surgeons to newly hired and still inexperienced administrative assistants, remained true to their calling: to treat every patient equally, with respect, consideration, and the same level of care regardless of their circumstances.