Some of those observations were correct. The interesting question was always why. Was it race, genetics, diet, poverty, culture, migration, discrimination, pollution, trauma, neighborhood, stress, or some complicated stew containing all of the above?

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Medicine and public health often look at the same person from different ends of a telescope. Medicine teaches us to look very closely at the patient. Public health says, “Fine, now stop staring at his pancreas for a minute and look out the window.” Where does he live? What does he eat? What happened to his parents? What kind of work does he do? What does his culture believe about illness? Is the grocery store three blocks away or twelve miles away? Is the air clean? Is the neighborhood safe? Does he trust doctors, and have doctors given him good reasons not to?

The more I think about systemic racism, culture, chronic stress, genetics and psychiatric diagnosis, the more I think medicine keeps making the same mistake: we discover a useful lens, then mistake it for the whole picture.

The Ghost in the Spirometer

The history of spirometry may be one of the clearest examples. For decades, pulmonary-function testing incorporated race into the interpretation of results. A Black patient and a White patient could produce the same measured lung volume, yet the number might be interpreted differently because the expected “normal” value was adjusted according to race.¹

Part of that history reaches back to the nineteenth century. Thomas Jefferson speculated about racial differences in pulmonary capacity. Louisiana physician, plantation owner and slaveholder Samuel Cartwright later used spirometry to argue that Black people had substantially lower lung capacity than White people.² Cartwright already believed in racial hierarchy, and, amazingly enough, his measurements discovered exactly what he already believed. Science can be extremely cooperative when you tell it the answer before beginning the experiment.

Cartwright even argued that forced labor benefited enslaved people by compensating for their supposed respiratory deficiency. That is almost a laboratory-perfect example of pseudoscience: begin with the conclusion, collect measurements, interpret the measurements through the conclusion, then announce that nature itself agrees with you.

The stranger part is that the assumption outlived Cartwright. Later scientists continued to observe average differences in pulmonary function among populations, and the measurements themselves were not necessarily imaginary. The question was what they meant. Lung development can be affected by childhood illness, pollution, nutrition, housing, tobacco, occupational exposure, socioeconomic status and access to health care. Genetic ancestry may matter too.³

Instead of treating race as a clue pointing toward possible mechanisms, medicine often treated race itself as the mechanism. Eventually the assumption became standardized, mathematical and computerized. Once something enters a machine, of course, it becomes official. Apparently racism wearing a white coat is questionable, but racism wearing an algorithm gets tenure.

A few things happened along the way:

• The racial assumption became an observation.

• The observation became an equation.

• The equation became an algorithm.

• The algorithm became “objective.”

• Nobody using it needed to remember where it came from.

That is one way systemic racism works. The prejudice no longer requires the prejudiced person. The system remembers it for you.

Race Is a Clue, Not a Mechanism

None of this means medicine should stop studying population differences. If one population develops diabetes twice as frequently as another, I want to know. If people with particular ancestry metabolize a medication differently, I definitely want to know. Pretending human populations are biologically identical would not be antiracism. It would be lousy medicine.

The problem comes with the next question: why?

The Japanese-American experience makes this wonderfully clear. Studies comparing Japanese Americans with people living in Japan found markedly different rates of diabetes, obesity and metabolic abnormalities despite shared ancestry.⁴ Their genes did not change somewhere over the Pacific. Customs did not stamp their passports and activate the American Diabetes Gene.

Their environment changed. Diet changed. Portions changed. Activity changed. Work changed. Stress changed. Culture changed. Bodies changed too. Research among Japanese Americans found that increased visceral adiposity, dietary patterns and reduced physical activity interacted with underlying metabolic susceptibility to increase diabetes risk.⁵

That makes the question more interesting, not less. Instead of asking, “Are Japanese people prone to diabetes?” we can ask, “What happens when this particular biology meets this particular environment?”

Race can help us locate a pattern. It does not automatically explain it.

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When the Tiger Moves In

There is a wonderful concept in medicine called allostatic load. Allostasis describes how the body keeps itself stable by changing. A tiger appears, your heart rate rises, your blood pressure rises, cortisol changes, glucose becomes available, and your body prepares you to do something useful, such as not become lunch.

Then the tiger leaves. Excellent arrangement.

The trouble begins when the tiger moves into the spare bedroom.

What if the threat is poverty, an unsafe neighborhood, racism, an abusive parent, food insecurity, working three jobs, chronic pain or wondering every month whether the rent check will bounce? The human stress system does not have a special setting labeled, “Relax, this is only a mortgage.”

Over time, adaptation itself has a cost. Sleep, blood pressure, metabolism, inflammation and cardiovascular risk can all change. Researchers Bruce McEwen and Eliot Stellar helped develop the concept of allostatic load to describe this cumulative physiological cost of adapting to repeated or chronic stress.⁶

Public-health researcher Arline Geronimus developed the related idea of “weathering,” describing how sustained social adversity and the effort required to cope with it can accumulate physiologically.⁷ The important point is not that one racial group possesses unusually fragile bodies. Quite the contrary: the hypothesis is about what human bodies do when repeatedly exposed to difficult environments.

Suddenly the neat distinction between “social” and “biological” starts looking fairly silly. The environment gets under the skin.

Biology Has a Biography

Imagine two populations living under substantially different conditions for generations: different wealth, housing, schools, pollution, occupational risks, medical care and levels of chronic stress. Then researchers arrive, draw blood, measure blood pressure and pulmonary function, and announce that they have discovered biological differences.

Well, yes. Where exactly did we expect the environment to go?

Finding a biological difference does not tell us what caused the difference. History can become hypertension. A neighborhood can become asthma. Poverty can become diabetes. Lead paint can become cognitive impairment. Chronic stress can become cardiovascular disease. Biology has a biography.

This is also why statements such as “Black Americans are more violent” tell us almost nothing. Suppose, just for the sake of argument, that someone hands me a perfectly accurate statistic showing a higher rate of a particular violent behavior in one population. Fine. Now we have an observation. We do not yet have an explanation.

Poverty? Residential segregation? Guns? Childhood exposure to violence? Schools? Employment? Lead? Drugs? Incarceration? Policing? Generational wealth? History? Probably several things at once, because apparently human beings refused to organize themselves into a clean randomized controlled trial.

These questions do not excuse an individual who commits violence. They ask why populations have different outcomes. Saying “because they’re Black” takes an observation requiring explanation and puts a period after it.

American history matters because slavery, Jim Crow, restrictive housing covenants and redlining were not accidents. Those systems affected where families could live, whether they accumulated property, which schools their children attended and what resources later generations inherited.⁸ Eventually the law can disappear while some consequences remain.

That is the “systemic” part.

Everybody Arrives Carrying Something

This is where I think the discussion often becomes needlessly competitive. There is no Olympic event for Most Historically Traumatized Population. Nobody wins a medal, and the prize would be terrible anyway.

Almost every population carries history. Indigenous American communities carry histories of dispossession, forced relocation, boarding schools and deliberate cultural destruction. Japanese American families may carry the history of internment. Jewish families carry histories of pogroms, displacement and the Holocaust. Southeast Asian American families may descend from refugees who survived war, genocide and forced migration. Black American families may carry the direct and indirect effects of slavery, Jim Crow, segregation and exclusion from wealth-building institutions. Poor Appalachian White communities have histories of geographic isolation, dangerous extractive industries and multigenerational poverty.

And then there are the quieter histories that never make it into textbooks: the alcoholic grandfather, the family that lost everything, the parent who survived war, the grandmother who never trusted hospitals, the father who learned that feelings were a luxury, the mother who stockpiles food because once there wasn’t any.

We inherit more than DNA. We inherit recipes, money, debt, neighborhoods, accents, religions, coping styles, family secrets, ideas about masculinity, ideas about illness, ideas about doctors, and occasionally a truly astonishing quantity of Tupperware.

There may even be biological pathways connecting one generation’s environment with the next. Research involving Holocaust survivors and their adult children has reported methylation differences involving FKBP5, a gene involved in stress regulation.⁹ This is fascinating, but it should not be inflated into the claim that traumatic memories are somehow written directly into the genes and handed to grandchildren like grandmother’s china. True transgenerational epigenetic inheritance in humans remains difficult to establish and scientifically contested.¹⁰

That’s actually more interesting than the simplistic version. A child may be influenced by a parent’s trauma through parenting, family stories, economic circumstances, prenatal physiology, culture, learned vigilance, social conditions and perhaps epigenetic mechanisms. Biology and environment keep refusing to remain in the separate boxes we built for them.

The point is not to look at the stranger next to you and diagnose eight generations of inherited trauma while waiting for coffee. The point is humility. The person beside you may be carrying things you cannot see.

That seems like an excellent thing for medicine to remember.

The Patient Brought a World With Them

Maybe this is my public-health training showing. Medicine taught me to look at the patient. Public health taught me to look around the patient.

Where does she live? What does she eat? What did her family teach her about illness? What happened to her parents? Who does she trust? What does her community consider normal? When does someone in her family go to a doctor, and when do they wait until an organ is actually hanging out?

We sometimes reduce this to “cultural competence,” which can make the entire subject sound like an international etiquette seminar. Japanese people bow. Americans shake hands. Take your shoes off here. Don’t make eye contact there. Congratulations, everyone gets a certificate.

Culture does something much more important. It helps determine what we think is happening to us. Is depression an illness, a weakness, a spiritual problem or something nobody talks about? Is alcoholism a disease or evidence of bad character? Is psychiatric medication treatment or proof that you’ve gone crazy? Who makes medical decisions? When is pain alarming? Who do you trust when you’re sick: a physician, a parent, a religious leader, an herbalist, YouTube, or your cousin who has “done a lot of research”?

Culture does not merely determine how we greet the patient. It helps determine how the patient understands being a patient.

Medicine Loves a Number

Then medicine confronted all this magnificent human complexity and did what medicine does best.

We made forms.

• Depressed? PHQ-9.

• Anxious? GAD-7.

• ADHD? Vanderbilt.

• Drinking too much? AUDIT.

• Suicidal? There’s a scale.

• Autistic? We have several scales, just in case autism wasn’t complicated enough already.

These tools are useful. I have used many of them. They are excellent for research, screening and following symptoms across populations. I rarely use them in my own practice, not because they’re bad, but because I have something they don’t: time.

When I meet a new patient, I spend 90 minutes with them. I would rather ask what happened.

A patient checks “nearly every day” when asked how often she has felt depressed. Good. Now I have a score. Maybe her husband died. Maybe she hates her job. Maybe she is being abused. Maybe she has bipolar disorder. Maybe she is sixteen and being bullied. Maybe she has severe ADHD and has spent thirty years believing she is stupid. Maybe she hasn’t slept properly in six months.

Same box checked. Entirely different person.

The metric measures something real. It just may not tell me what the thing is.

Comedian George Carlin once said, “I love individuals. I hate groups of people.”¹¹ His larger joke was about how quickly groups acquire slogans, uniforms and enemies, but buried inside it is a pretty good clinical principle: the closer you get to actual individual human beings, the harder it is to maintain elegant theories about what “those people” are like.

The Problem With Compression

Medicine has to categorize people. Without categories, medical science would be impossible. Diagnoses, demographics and risk factors allow us to study millions of people and discover patterns that no individual physician could ever see.

But categorization is compression, and compression always loses information.

Racism performs an especially crude and destructive version of that maneuver. Millions of radically different human beings become “Black people are violent.” No neighborhood, no family, no school, no history, no individual personality. Most importantly, no need to meet anybody.

The category has replaced the person.

There is obviously a vast moral difference between a PHQ-9 and racism, but there is a cognitive warning common to both: classification can become a substitute for curiosity.

Public health asks, “What tends to happen to people like this?” Clinical medicine asks, “What is happening to this person?” Good medicine has to move constantly between them.

We tend to call everything the category missed “nuance.” I think that’s too weak a word. Nuance sounds like something you add after the important stuff, like parsley.

What if the context is the important stuff?

Where someone grew up isn’t nuance if the neighborhood exposed them to lead. Poverty isn’t nuance if it determined what they ate. Racism isn’t nuance if chronic stress affected cardiovascular health. Childhood trauma isn’t nuance if it shaped the stress response for decades.

Sometimes the details around the disease are how the disease happened.

Choosing the Story First

This also helps explain pseudoscience. Pseudoscience does not mean an idea mainstream scientists currently reject. Scientists have rejected good ideas before. An unconventional hypothesis becomes science when evidence supports it.

Pseudoscience does something different. It borrows the authority of science without accepting the rules. Start with the answer, collect confirming evidence, ignore contradictory evidence, elevate anecdotes and change the standard of proof depending on which side the evidence supports.

The theory can never lose.

That isn’t skepticism. It’s faith with a PubMed search.

The same problem appears in revisionist stories about measles and polio. Vaccines became victims of their own success. Before measles vaccination, an estimated 3 to 4 million Americans were infected each year, about 48,000 were hospitalized, roughly 1,000 developed encephalitis, and 400 to 500 died.¹² Most children recovered. Both statements are true.

Polio makes the same point even more dramatically. Most infections did not cause paralysis, but in 1952 alone the United States reported more than 20,000 cases of paralytic polio.¹³ Some people lost the ability to walk or breathe. Then vaccination arrived, disease collapsed, and eventually generations grew up having never seen polio.

Once a disease disappears, it becomes surprisingly easy to wonder why everybody made such a fuss.

Exactly. That’s what success looks like.

The problem with revisionist arguments promoted by Robert F. Kennedy Jr. and others isn’t that they question vaccines. Question vaccines. Question everything. The problem is skepticism that operates in only one direction, where every possible vaccine injury is magnified and the consequences of infection become an historical footnote.¹⁴

That is not balanced skepticism. It is choosing the story first.

Comedian Chris Rock made a related point about historical framing when he objected to describing racial history simply as “Black progress.” His joke works because it moves the camera from the group being measured to the society that created the original conditions.¹⁵ That is exactly the camera movement public health keeps asking us to make.

Pull the Camera Back. Then Pull It In.

A physician sees a 52-year-old man with hypertension. Pull the camera back and you discover that he sleeps five hours and works two jobs. Pull back farther and he lives beside an interstate. His parents lived in the same neighborhood. Keep pulling back and suddenly we’re looking at housing, pollution, employment, segregation, wealth and history.¹⁶

But you can pull the camera so far backward that the patient disappears. That’s a mistake too.

So psychiatry pulls it back in. There he is, one person sitting across from me.

That is why I want the 90 minutes. Eventually I’m going to do something fairly presumptuous and tell this person what I think they should do next. Before I do that, I’d like to know who the hell I’m talking to.

Science gives me populations. Public health gives me environments. History gives me context. Genetics gives me predispositions. Culture gives me meaning. Medicine gives me diagnoses. The patient gives me the story.

None of those perspectives is sufficient alone, which may be the whole point. We need the population to understand the person, but we also need the person to prevent the population from becoming a stereotype.

The category tells us where to look. The story tells us what we’re looking at.

Notes and Sources

1. Lundy Braun, Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics, University of Minnesota Press, 2014.

2. Lundy Braun, Breathing Race into the Machine, University of Minnesota Press, 2014.

3. American Thoracic Society, “Race and Ethnicity in Pulmonary Function Test Interpretation: An Official American Thoracic Society Statement,” American Journal of Respiratory and Critical Care Medicine, 2023.

4. Wilfred Y. Fujimoto et al., “Risk Factors for Type 2 Diabetes: Lessons Learned from Japanese Americans in Seattle,” Journal of Diabetes Investigation 3, no. 3 (2012): 212–224.

5. Wilfred Y. Fujimoto et al., “Risk Factors for Type 2 Diabetes”; Masayasu Yoneda and Kazuhiro Kobuke, “A 50-Year History of the Health Impacts of Westernization on the Lifestyle of Japanese Americans,” Journal of Diabetes Investigation 11, no. 6 (2020): 1382–1387.

6. Bruce S. McEwen and Eliot Stellar, “Stress and the Individual: Mechanisms Leading to Disease,” Archives of Internal Medicine 153, no. 18 (1993): 2093–2101; Bruce S. McEwen, “Protective and Damaging Effects of Stress Mediators,” New England Journal of Medicine 338 (1998): 171–179.

7. Arline T. Geronimus, “The Weathering Hypothesis and the Health of African-American Women and Infants,” Ethnicity & Disease 2, no. 3 (1992): 207–221.

8. Richard Rothstein, The Color of Law: A Forgotten History of How Our Government Segregated America, Liveright, 2017; National Academies of Sciences, Engineering, and Medicine, Examining the History, Consequences, and Effects of Race-Based Clinical Algorithms on Health Equity, National Academies Press.

9. Rachel Yehuda et al., “Holocaust Exposure Induced Intergenerational Effects on FKBP5 Methylation,” Biological Psychiatry 80, no. 5 (2016): 372–380.

10. Edith Heard and Robert A. Martienssen, “Transgenerational Epigenetic Inheritance: Myths and Mechanisms,” Cell 157, no. 1 (2014): 95–109.

11. George Carlin, comedy material on individuals, groups and identity.

12. Centers for Disease Control and Prevention, historical measles epidemiology.

13. Centers for Disease Control and Prevention, historical poliomyelitis surveillance.

14. Centers for Disease Control and Prevention; U.S. Department of Health and Human Services; public statements by Robert F. Kennedy Jr. concerning vaccine-preventable disease.

15. Chris Rock, interview with Frank Rich, “Chris Rock Talks to Frank Rich About Ferguson, Cosby, and What ‘Racial Progress’ Really Means,” New York Magazine, November 30, 2014.

16. David R. Williams, Jourdyn A. Lawrence, and Brigette A. Davis, “Racism and Health: Evidence and Needed Research,” Annual Review of Public Health 40 (2019): 105–125.

17. Nancy Krieger, Epidemiology and the People’s Health: Theory and Context, Oxford University Press, 2011.

18. National Academies of Sciences, Engineering, and Medicine, Communities in Action: Pathways to Health Equity, National Academies Press, 2017.

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Maybe that’s why I studied it. Clean water, sewers, vaccination, food safety, lead-free paint, clean air, washing our hands. There is something almost audacious about organizing a society around the health of people we will never meet. I remember studying infectious diseases during internal medicine and learning a wonderfully simple principle: germs don’t understand boundaries. They don’t recognize property lines, state lines, political parties or constitutional rights. A virus leaving my respiratory tract doesn’t pause in midair to ask whether the person inhaling it consented to my medical choices.

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Somewhere along the way, though, we became very interested in me: my body, my choice, my taxes, my money, my freedom, my health. All perfectly reasonable concepts, but what happened to we?

Someone Else Lives Here Too

When I was younger, people smoked everywhere: restaurants, offices, airplanes, hotels, even hospitals. Then we learned what secondhand smoke did. Laws mattered, but something larger happened. We changed. Lighting a cigarette beside someone eating dinner went from perfectly ordinary to almost unimaginable because we absorbed a fairly sophisticated moral idea: you have considerable freedom to make choices about your own health, but that freedom becomes more complicated when I have to breathe it.

We understand the same principle when we go camping. Leave nothing but footprints. Pack out the beer can. Don’t dump garbage into the stream. Nobody has to introduce me to the child hiking there fifty years from now before I decide that child deserves a trail I haven’t ruined. Jerry Garcia, of all people, put it beautifully when talking about freedom: “For any scene to work, along with that freedom there’s implicit responsibility.”¹ He wasn’t talking about public health, but he could have been.

Then COVID arrived and I began hearing another phrase constantly: I’m healthy. Aaron Rodgers said versions of it. Joe Rogan said versions of it. I’m young, I exercise, I take care of myself, my immune system works. Why should I worry?

And every time I heard it, my public-health brain had almost exactly the same response: That’s great. But IT’S NOT ABOUT YOU.

I’m worried about the little old lady you breathe on at Safeway. Maybe she’s 91, receiving chemotherapy or taking an immunosuppressant. Maybe she’s an infant who hasn’t yet been vaccinated. You don’t know her, which is precisely the point. Public health asks us to care about people we don’t know.

Anthony Fauci described vaccination during COVID as part of our “communal responsibility” to contain the outbreak.² This doesn’t mean every mandate was wise or every COVID policy correct. Some weren’t. It means infectious disease cannot be reduced to the question What are my chances of getting very sick? Your infection doesn’t necessarily stop with you.

Why Would Anyone Want Measles?

The same problem appears in the romance with “natural immunity.” Yes, infection can produce immunity. Humanity had a remarkably effective method of acquiring natural immunity to measles before vaccination: you got measles.

Most people recovered. Some developed pneumonia or encephalitis; some died. Rarely, people who seemed to recover later developed a progressive and fatal neurological disorder called subacute sclerosing panencephalitis. Measles is also among the most contagious infectious diseases humans know, with the traditional estimate suggesting that one infected person in a susceptible population may infect roughly 12 to 18 others.³

So when someone celebrates natural infection because it produces natural immunity, I get stuck on an obvious question: why do you want the disease? Vaccination is an attempt to obtain the useful part of the immune response without requiring everyone to run the disease obstacle course first.

Polio makes the nostalgia even harder for me to understand. Most people infected with poliovirus didn’t become paralyzed, but some did, and sometimes the virus damaged the motor neurons controlling the muscles required for breathing. That’s where the iron lung came in. The patient’s body went inside a huge metal cylinder while the head remained outside, and changing air pressure around the chest mechanically drew air into the lungs.

The machine breathed because the patient couldn’t.

When I first worked at Children’s Hospital, one of my superiors still walked with a limp from polio he’d contracted as a child. This was roughly sixty years later. Polio was still walking with him.

Nature isn’t benevolent or malevolent. Nature doesn’t care. Polio is natural. Measles is natural. Smallpox was natural. So are rattlesnakes. “Natural” is not a synonym for “good.”

How Did Anthony Fauci Become the Criminal?

I take the transformation of Fauci into a political villain somewhat personally. When I studied internal medicine, his name meant something entirely different. He was a longtime editor of Harrison’s Principles of Internal Medicine, the enormous two-volume textbook that was essentially our bible. Harrison’s wasn’t something you casually read at the beach. It was where you went when you wanted to know what the hell you were talking about.

Fauci entered the NIH in 1968, became director of the National Institute of Allergy and Infectious Diseases in 1984 and remained there for 38 years. His career encompassed HIV/AIDS, influenza, Ebola, Zika and COVID. He was also deeply involved in the development of PEPFAR, George W. Bush’s global AIDS initiative, one of the most consequential public-health programs of the modern era.

Yet now I can say “Fauci” and occasionally hear something like, Oh, him. The criminal.

Huh?

There are legitimate questions about COVID policy, Wuhan research, NIH funding, government transparency and Fauci’s congressional testimony. Investigate them. Ask difficult questions. But somehow a public official whose decisions can be questioned became the architect of all our suffering. Fauci became a character representing lockdowns, vaccines, masks, China, pharmaceutical companies and apparently everything unpleasant that happened between March 2020 and the day we finally stopped wiping down our groceries.

The irony is that successful public health tends to erase the evidence of its own success. There is no photograph of the child who wasn’t paralyzed. Nobody builds a memorial to the measles encephalitis that never occurred or wakes up thinking, Thank God the sewage system worked again. The outbreak didn’t happen. The water didn’t transmit cholera. The child didn’t get polio.

Eventually people mistake nothing happening for evidence that nothing was ever going to happen. The disease disappears, but the vaccine remains. The vaccine is visible; the disease isn’t. The intervention begins looking more frightening than the catastrophe we’ve forgotten.

That’s not natural immunity. It’s cultural amnesia.

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Apparently Doctors Are Supposed to Know Everything

This brings me to Bill Maher. I used to admire him. I still think he’s funny and can be excellent at identifying bullshit, but his longstanding skepticism toward medicine fascinates me because it contains much of our current distrust of expertise in miniature.

Maher has repeatedly made some version of the argument that doctors don’t know his body; he does. There’s an important truth buried in there. A patient knows things about his own experience that I don’t. If someone tells me a medication makes him feel terrible, I don’t get to say, No it doesn’t. Look, I have a medical degree.

But I know my experience isn’t the same claim as I understand how my body works better than people who have spent their careers studying human bodies.

For most of human history, distrust of doctors wasn’t entirely irrational. We bled people, purged them, administered mercury and recommended treatments that were useless and sometimes spectacularly harmful. The remarkable thing is that distrust of medicine has intensified during the relatively brief period when medicine became extraordinarily good at actually doing things.

The same skepticism has spread beyond medicine. We’ve entered a cultural moment in which expert can almost sound like an insult. Experts said this. Experts were wrong about that. Experts told us masks. Experts told us vaccines. Therefore, experts don’t know anything.

That’s an extraordinary leap. An expert isn’t somebody who possesses absolute truth. An expert is somebody who has spent an unreasonable amount of time learning about one narrow part of reality. Of course experts are sometimes wrong. The relevant question isn’t whether your infectious-disease specialist has ever been wrong. It’s whether you’re more likely to be right.

Put Neil deGrasse Tyson in front of us and ask what dark matter actually is or what happened before the Big Bang. Eventually we arrive at a sophisticated version of we don’t know, and everybody leans forward. Fascinating. A physician says, We don’t completely understand why this treatment works, but controlled trials show that people receiving it improve more often, and suddenly the medical establishment knows nothing.

Apparently the universe is allowed to be complicated. My pancreas is not.

Richard Feynman said, “I can live with doubt and uncertainty and not knowing.”⁴ That’s not an embarrassing admission from a scientist. It’s practically the job description. The alternative to uncertain expertise isn’t certainty. It’s often someone who knows considerably less being absolutely certain.

Actually, I Was Wrong About That Too

I remember learning during medical training that Victorian physicians treated “hysterical” women by bringing them to orgasm, eventually adopting mechanical vibrators because doing it manually became tedious. It’s an irresistible story.

It also appears not to be true.

The idea became famous after Rachel Maines’s 1999 book The Technology of Orgasm. Later historians Hallie Lieberman and Eric Schatzberg went back through the primary sources and found that the evidence did not support its central claim.⁵ Doctors really did use mechanical vibrators therapeutically, but the familiar image of exhausted Victorian physicians spending their afternoons producing therapeutic orgasms appears largely to be mythology.

I believed it too. So what am I supposed to do now, insist it’s true because somebody taught it to me?

The history underneath the myth remains disturbing. “Hysteria” became an elastic diagnosis applied disproportionately to women, and medicine spent centuries confidently interpreting women’s physical and emotional lives through overwhelmingly male assumptions. The therapeutic-orgasm story may be mythology; medicine’s spectacular confidence while misunderstanding women isn’t.

But the correction itself matters. Somebody checked the sources and discovered that a wonderfully memorable story didn’t survive scrutiny. That’s not evidence that scholarship doesn’t work. That’s what scholarship working looks like.

Psychiatry May Be the Best Example

I see the same tension especially clearly because I’m a psychiatrist. For most of human history, if somebody became psychotic, profoundly depressed, manic, suicidal or incapacitated by anxiety, we didn’t know what was happening. We had explanations: demons, sin, weakness, bad character, masturbation, bad parenting. Eventually Freud gave us mothers.

But explanations aren’t treatments.

We still don’t completely understand the human psyche or brain, and we haven’t discovered a final theory of consciousness, personality or emotion. But something fundamental has changed: we can help now. Not everybody, perfectly or every time, but the difference between psychiatry today and psychiatry a century ago is extraordinary.

People also misunderstand what we’re trying to accomplish. My job isn’t to make somebody happy. Happiness isn’t a medical condition. You may get it falling in love, eating a great meal, hearing Jerry Garcia play an extraordinary solo, or taking acid in the woods at a concert, although I am not recommending that as a treatment plan.

My job is less glamorous. I help people function. I try to reduce suffering enough that somebody can get out of bed, attend school, hold a job, maintain a relationship, sleep, concentrate, stop wanting to die or simply get through Tuesday without existence feeling unbearable. Contentment is a reasonable ambition. The absence of relentless suffering is an extraordinary achievement.

Happiness belongs to life.

Science Is Supposed to Change

Maybe medicine became so effective that we started expecting omniscience. If my oncologist can cure my lymphoma, why can’t she predict with certainty whether it will recur? If my psychiatrist treats depression, why can’t he know beforehand which medicine will work? Because biology is complicated. There are probabilities, individual differences and mechanisms we haven’t discovered, and sometimes we’re wrong.

Good.

I remember what I learned in medical school. Some remains true, some has been refined and some has been replaced. I hope today’s medical students can say the same thing forty years from now. Imagine opening a medical textbook from 1926 and discovering everything in it was still accepted in 2026. That wouldn’t demonstrate medicine’s wisdom. It would mean we’d learned nothing.

• Childhood leukemia in 1926: overwhelmingly fatal.
• Insulin before 1922: unavailable.
• Effective combination HIV treatment in 1985: not yet available.
• Antibiotics before the twentieth century: mostly nonexistent.
• Amount left to learn about the human body: an impressive amount.

I want somebody challenging my doctor. I want the larger study, the better imaging technique and the researcher discovering a mechanism nobody knew existed. I want the textbook rewritten.

Science isn’t a warehouse where facts sit after somebody stamps TRUE on them. It’s a method for becoming progressively less wrong.

We Became Me

This brings me back to public health. I don’t think Ronald Reagan invented selfishness; humanity had mastered it long before 1981. But his presidency gave modern American individualism an extraordinarily successful vocabulary. In his first inaugural address, Ronald Reagan famously said, “government is not the solution to our problem; government is the problem.”⁶ The sentence had a context more complicated than its later use, but the cultural message endured: my money, my taxes, my property, my responsibility.

Individual liberty matters, and skepticism of government matters. Governments can be spectacularly wrong. But a society composed entirely of individuals eventually runs into a sewer problem.

I cannot have my own herd immunity, atmosphere or electrical grid. I cannot individually prevent an epidemic or have clean drinking water if everyone upstream believes the river is exclusively their personal property. Civilization is the stuff we have to do together.

Maybe that helps explain why some younger Americans are attracted to democratic socialism. Perhaps they’ve all become dedicated students of Marx. I suspect many simply want a functioning bus, affordable housing, health care, schools and public spaces that work. Maybe what attracts them isn’t collectivization so much as the collective.

Maybe the radical word isn’t socialism. Maybe it’s we.

Someone Else Lives Here Too

Which brings me back to the hiking trail. I don’t throw my garbage into the stream because somebody drinks downstream. I don’t smoke beside you because you have lungs. I vaccinate partly because somebody else’s immune system may not work as well as mine. None of this requires me to love you, agree with you or even like you. It requires me to acknowledge that you exist.

It’s not about you.

That’s not an insult to individual freedom. As Jerry Garcia understood, freedom comes with “implicit responsibility.” That’s how the scene works.

Everybody wants to go back these days. Fine. I’d like to go back too, but not to iron lungs, measles or smoke-filled restaurants. I’d like to go back to something much older: we.

Science says I don’t know everything. Democracy says I don’t decide everything. Public health says I’m not the only person who matters. We don’t know everything, which is why we need science. We don’t agree about everything, which is why we need democracy. And we can’t survive everything alone, which is why we need each other.

Someone else lives here too.

Notes and Sources

1. Jerry Garcia, interview with Charles Reich, Rolling Stone, 1972.

2. Anthony S. Fauci, interviews on vaccination as individual protection and a “communal responsibility,” PBS NewsHour, June 29, 2021; CBS News, December 19, 2021.

3. Centers for Disease Control and Prevention, MMWR, “Real-Time Use of a Dynamic Model to Measure the Impact of Public Health Interventions on Measles Outbreak Size and Duration,” 2024; CDC measles epidemiology and complications materials.

4. Richard P. Feynman, “The Pleasure of Finding Things Out,” BBC Horizon, 1981; later collected in The Pleasure of Finding Things Out.

5. Hallie Lieberman and Eric Schatzberg, “A Failure of Academic Quality Control: The Technology of Orgasm,” Journal of Positive Sexuality, Vol. 4, No. 2, 2018; Rachel P. Maines, The Technology of Orgasm, Johns Hopkins University Press, 1999.

6. Ronald Reagan, First Inaugural Address, January 20, 1981.

7. Fauci AS et al., eds., Harrison’s Principles of Internal Medicine, multiple editions, McGraw-Hill.

8. National Institutes of Health, biographical and historical materials on Anthony S. Fauci and the National Institute of Allergy and Infectious Diseases.

9. U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), U.S. Department of State, historical and program-impact materials.

10. Centers for Disease Control and Prevention, “About Polio” and historical materials on poliomyelitis and vaccination.

11. Smithsonian National Museum of American History, historical materials on the iron lung and negative-pressure ventilation.

12. Centers for Disease Control and Prevention, measles transmission, complications and vaccination materials.

13. National Cancer Institute, historical materials on childhood acute lymphoblastic leukemia treatment and survival.

14. University of Toronto, Banting & Best Diabetes Centre, historical materials on the discovery and clinical introduction of insulin, 1921–1922.

15. National Institutes of Health, Office of NIH History and Stetten Museum, HIV/AIDS treatment history and the development of combination antiretroviral therapy.

16. Centers for Disease Control and Prevention and U.S. Environmental Protection Agency, historical materials on secondhand tobacco smoke and smoke-free public-health policy.

17. World Health Organization, measles and poliomyelitis fact sheets and vaccination materials.

18. PBS FRONTLINE, interview with Anthony Fauci, The Vaccine War, 2010, on vaccination, herd immunity and protection of people who cannot be adequately immunized.

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This wouldn’t ordinarily matter. Millions of adolescent boys read Isaac Asimov, Frank Herbert, Arthur C. Clarke and Douglas Adams. Most emerged relatively unharmed. We read Dune without deciding humanity needed an all-powerful messiah. We read 1984 without thinking the telescreens sounded promising. We read The Hitchhiker’s Guide to the Galaxy and understood, I thought, that Douglas Adams was making fun of us. But most of us didn’t become the richest person on Earth.

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For years, we cast Musk as Tony Stark, the eccentric billionaire genius who would save humanity through technology. He even appeared in Iron Man 2, standing beside Robert Downey Jr., just in case the metaphor was too subtle. Bezos was taking us into space, Zuckerberg was connecting humanity, the Google guys were organizing all human knowledge. Billionaires weren’t merely rich anymore. They were visionaries, disruptors, superheroes. Somewhere along the way, however, the superheroes started looking suspiciously like supervillains.

George Carlin once asked, “Where do people think these politicians come from? They don’t fall out of the sky.” Maybe the same applies to billionaires. We created a culture in which accumulating an unimaginable amount of money somehow became evidence that you must also possess an unimaginable amount of wisdom.

Those aren’t the same thing.

The Man Who Mistook Himself for Tony Stark

With apologies to Oliver Sacks and The Man Who Mistook His Wife for a Hat, which was about something considerably more humane.

The popular Tesla story has Musk inventing the electric-car company and becoming its eccentric genius-founder. The history is messier. Martin Eberhard and Marc Tarpenning incorporated Tesla Motors before Musk joined the company as its major early investor and chairman. The disagreement over who deserved to be called a founder eventually became part of a bitter lawsuit. When the dispute was settled in 2009, Tesla described Musk and Eberhard as two of five co-founders.¹

The Roadster story is better. According to allegations Eberhard made in that lawsuit, he was originally supposed to receive production Roadster No. 1. Musk wanted it. Eberhard agreed to take No. 2. Musk got the first car.² Then, in 2018, Musk strapped his cherry-red Roadster to the inaugural Falcon Heavy and fired it into space.

There was a mannequin named Starman behind the wheel and DON’T PANIC on the dashboard, courtesy of Douglas Adams. Also aboard was a quartz data-storage device designed to survive for millions of years containing Isaac Asimov’s original Foundation trilogy. The Arch Mission Foundation says the library remains in the Roadster’s glove compartment, orbiting the Sun.³

This is Comic-Con with a defense budget.

But Foundation matters. Asimov imagined a Galactic Empire in collapse and Hari Seldon, a mathematician who develops “psychohistory,” allowing him to predict the behavior of enormous populations. Seldon cannot prevent the coming dark age, but because he understands where history is going, he believes he can manipulate events to shorten it.

You can see the attraction. Seldon knows where history is going. Most people don’t. And because he knows, he gets to chart the course.

• Science fiction asks: What happens when a tiny group of people determines humanity’s future?
• Silicon Valley apparently heard: Where do we apply?
• Hari Seldon predicts the collapse of civilization.
• Elon Musk puts Foundation in a Tesla and shoots it into space.
• Douglas Adams spends an entire career mocking human self-importance.
• Somehow the billionaires missed that part.

Historian Jill Lepore has recently taken this idea considerably further, arguing that figures such as Musk and Sam Altman have treated science fiction less as a warning than as a blueprint for technological transcendence.⁴ The interesting question isn’t why Musk likes science fiction. Lots of us do. It’s what happens when people with extraordinary resources begin treating speculative futures not as possibilities for society to consider, but as destinations humanity is already headed toward.

The Ordinary Constraints of Human Existence Are Engineering Problems

Maybe the easiest way to understand this worldview is through one idea: the ordinary constraints of human existence are engineering problems. Distance became transportation. Gravity became rockets. Aging becomes cellular rejuvenation. Death becomes longevity research or cryonics. Earth becomes Mars. Human intelligence becomes artificial intelligence. The brain becomes something we can connect to a computer. Reproduction becomes something else to optimize.

At some point, the final engineering problem becomes being human.

I don’t object to the engineering impulse. Much of civilization exists because somebody looked at an apparently immovable constraint and said, That’s ridiculous. We can fix that. If somebody cures Alzheimer’s disease, wonderful. If someone safely extends healthy human life by twenty years, sign me up.

Musk isn’t alone in pushing against ordinary human limits. Silicon Valley money has poured into longevity research. Peter Thiel has supported anti-aging research; Jeff Bezos has been reported among the backers of cellular-rejuvenation company Altos Labs; and Sam Altman put $180 million into Retro Biosciences, whose goal is to extend healthy human lifespan.⁵ ⁶ Bryan Johnson has taken the project to its logical and wonderfully strange conclusion, spending millions measuring and modifying his own body in an attempt to slow biological aging.⁷

Kings built pyramids. Emperors searched for elixirs. Silicon Valley has venture capital.

Extreme wealth, however, introduces an interesting possibility. Most of us spend our lives encountering limits. We can’t buy that. We can’t go there. We can’t make that person do what we want. Eventually reality says no. What happens when reality almost never says no? Perhaps death itself begins looking less like the human condition and more like inadequate product design.

And once technology moves from solving human problems to deciding what a better human should be, we’ve quietly left engineering. We’ve entered ethics and politics.

Who Gets to Build the Humans?

Then there is reproduction. Musk has repeatedly warned about falling birth rates, and his own family has become part of his pronatalist project. Reporting by The Wall Street Journal described at least fourteen children with at least four women and said Musk has privately discussed creating a “legion” of children, with intelligence and the survival of civilization explicitly entering the discussion.⁸

This becomes more interesting than simple pronatalism because the question isn’t merely whether humanity needs more babies. It is: more babies by whom?

Musk’s estranged transgender daughter Vivian Jenna Wilson added an extraordinary wrinkle when she alleged in 2025 that her sex had been deliberately selected through IVF. Vivian Jenna Wilson wrote that her “sex at birth was a commodity that was bought and paid for,” connecting that decision to an expectation that she would be male and masculine.⁹ This remains her allegation about a private reproductive decision, not an independently established fact, and it would be wrong to leap from it to the claim that Musk exclusively selects male embryos.

But once reproduction becomes another optimization problem, uncomfortable questions follow naturally. What are we optimizing? Sex? Intelligence? Height? Disease risk? Temperament? And who defines improvement?

We need more babies is one proposition. We need more babies from particular kinds of people has a considerably longer and darker history.

There’s also something difficult not to notice about the people explaining humanity’s future to us. They’re mostly men. Obviously there are brilliant women throughout computing, biotechnology and AI. That’s not the point. Look instead at this particular cultural pantheon: Musk, Thiel, Zuckerberg, Bezos, Altman, Andreessen, Ellison. Men building AI, contemplating Mars, funding life extension, worrying about fertility and speculating about how humanity might need to change.

Where are the female tech bros?

This particular combination of extreme wealth, techno-utopianism, pronatalism, libertarianism and increasingly authoritarian politics is remarkably male. That becomes especially interesting when reproductive politics simultaneously moves toward more traditional gender roles. Women become increasingly important as producers of the next generation at exactly the moment powerful men become increasingly interested in what that generation should look like.

That isn’t evidence of a conspiracy. It’s a pattern worth noticing.

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Welcome to the Silo

This is why I keep thinking about the Apple TV series Silo. Humanity lives underground, where space and resources are limited, so couples enter a lottery for permission to have children. Initially that makes sense.

Then we discover the lottery isn’t quite a lottery. The authorities aren’t simply determining how many people reproduce. They’re influencing which people reproduce. People who question the system, investigate its history or display characteristics that might destabilize the social order aren’t particularly desirable additions to the gene pool. Population control has quietly become social control.

What makes Silo interesting isn’t that its rulers are cartoon villains. They’re preserving what they believe to be the last remnants of humanity. Their secrecy and manipulation become defensible because the stakes are existential. If everyone knew everything and participated equally in every decision, they believe the entire civilization might disappear.

That’s a much more interesting authoritarian temptation than simple lust for power. Once the stakes become the survival of humanity, almost anything can be justified.

And Silicon Valley talks about the survival of humanity quite a lot.

Nobody Voted for This Future

Artificial intelligence makes the issue concrete because we’re constantly told AI is going to transform employment, medicine, education, warfare, art, entertainment, relationships and politics. It may eventually exceed human intelligence. Perhaps all of that will happen. What interests me is how rarely anyone asks: Would you like to?

Technological development is increasingly presented like weather. It’s coming. Prepare accordingly. And now we have the geopolitical trump card: China. The U.S.-China competition over advanced AI is quite real; both governments increasingly treat leadership in AI as a strategic national priority.¹⁰ What follows from that fact, however, is a different question. Competition can easily become the argument that whatever can be built must be built, and built quickly.

There is something beautifully convenient about this argument when the people explaining why AI must advance rapidly are also among the people who stand to become spectacularly wealthy if it does. Meanwhile, public distrust and anxiety about AI have grown substantially.¹¹

• Number of Americans asked whether they want artificial superintelligence: approximately none.
• Number routinely told it is inevitable: everybody.
• Primary reason we cannot slow down: China.
• Secondary reason: somebody else will do it.
• People financially rewarded if development accelerates: strangely familiar.
• Possibility apparently unavailable for discussion: maybe slow down and think.

This isn’t an argument to stop AI. I use AI. I think it is extraordinary. I also drive a car without believing Henry Ford should have been allowed to design the interstate highway system, traffic laws, zoning regulations and the future structure of American cities by himself.

Technology and governance are different things.

Secondhand Technology

Maybe we need a concept of secondhand technology.

We eventually understood secondhand smoke. You may choose to smoke, but once your smoke enters my lungs, your private decision becomes partly a public question. Pollution works the same way. Your factory may be private property; the river downstream isn’t.

Social media taught us this lesson considerably later. You didn’t have to join Facebook for Facebook to alter your school, politics, friendships, culture and information environment.

AI may be the largest version yet. I don’t have to choose AI for it to change my labor market. I don’t have to use a chatbot for AI-generated information to enter my elections. I don’t have to own a data center for one to consume electricity and water in my community. Current public opposition to data centers is already being driven in part by concerns about electricity prices, environmental costs and local resources.¹²

I don’t have to want artificial superintelligence to live in whatever world artificial superintelligence creates.

The automobile was an extraordinary invention. So was the airplane. So was nuclear energy. None remained solely the private concern of the people who invented it once its effects spilled into everyone else’s lives.

AI shouldn’t be different.

When the Builders Discover Power

Musk’s political evolution makes this increasingly difficult to treat as a purely technological discussion. He openly supported Germany’s far-right Alternative für Deutschland, or AfD, and appeared by video at one of its campaign events in January 2025. There, two days before International Holocaust Remembrance Day, Musk told the crowd that Germany had “too much focus on past guilt” and said children should not bear the guilt of their ancestors.¹³

Days earlier, his gesture at a celebration following Donald Trump’s inauguration had caused international controversy. Musk placed a hand to his chest and then extended his right arm upward, prompting comparisons to a Nazi salute. The Anti-Defamation League argued that it appeared to be an awkward gesture made in enthusiasm rather than a Nazi salute, while others strongly disagreed.¹⁴

I don’t need to decide what was inside Musk’s head when his arm went up, diagnose him, or call him a Nazi. I’m more interested in why a strain of techno-libertarianism that once seemed almost allergic to government increasingly appears comfortable with concentrated political power.

Perhaps it isn’t contradictory. Libertarianism objects to someone else having authority over the exceptional individual. It doesn’t necessarily tell us what the exceptional individual will do once he acquires authority himself.

The person who believes he understands the future better than everyone else may eventually find democracy terribly inefficient.

The Problem Isn’t Intelligence

This is where I think science fiction has something important to tell us, and it isn’t how to build a rocket.

Maybe Musk is right. Maybe humanity needs Mars. Maybe artificial intelligence will save civilization. Maybe humans will merge with machines, live for 300 years and spread throughout the galaxy. Maybe declining fertility really is among civilization’s greatest threats.

I don’t know. Neither does Elon Musk, Sam Altman, Peter Thiel or anyone else, which isn’t an insult to them. It’s the human condition.

Science fiction’s great subject was never really spaceships, robots or distant planets. Its great subject was what humans do when they acquire extraordinary power: how certain they become, who gets sacrificed for the future, who defines progress and what happens when someone convinced he is saving civilization becomes incapable of imagining that he might be wrong.

Science works because it institutionalizes doubt. Evidence changes, models fail, experiments are replicated, other scientists challenge you, and today’s brilliant theory may become tomorrow’s historical curiosity. Democracy institutionalizes a related humility. I may be wrong. You may be right. Therefore neither of us gets to decide everything.

That’s what worries me about the intersection of enormous wealth, technology and political power. The danger isn’t stupidity. These are obviously intelligent people. It’s intelligence combined with resources so vast that ordinary constraints disappear, and enough certainty to believe that the future has already been decided.

• Science asks for evidence.
• Democracy asks for consent.
• Science fiction asks what could go wrong.
• Billionaires increasingly seem to ask how soon they can ship it.

Maybe Elon Musk really is trying to save humanity. That’s what makes the story interesting.

Before we engineer our children, defeat aging, connect our brains to computers, hand increasing amounts of human thought to machines and begin relocating civilization to Mars, I’d like to ask something almost embarrassingly old-fashioned:

Who decided this was the future?

Science fiction warned us repeatedly about powerful people deciding humanity’s destiny. Somehow we read the books and decided the lesson was to build the machines.

I thought the lesson was to watch the humans.

Notes and Sources

1. Ken Bensinger, “Tesla Founders End Bitter Legal Fight,” Los Angeles Times, September 22, 2009.

2. Chuck Squatriglia, “Tesla’s Founder Sues Tesla’s CEO,” Wired, June 11, 2009.

3. Arch Mission Foundation, “The Foundation Library: Isaac Asimov in Space,” 2018.

4. Jill Lepore, “Elon Musk, Sam Altman, and the Misreading of Science Fiction,” Wired, August 2026.

5. Methuselah Foundation, “Longevity Research Is a Magnet for Innovation,” March 24, 2022.

6. Ashlee Vance, “The Most Secretive Longevity Lab Finally Opens Its Doors,” Bloomberg Businessweek, December 19, 2023.

7. Bryan Johnson, Blueprint Project, longevity and biological-aging materials.

8. Kirsten Grind et al., “The Tactics Elon Musk Uses to Manage His ‘Legion’ of Babies—and Their Mothers,” The Wall Street Journal, April 2025.

9. Vivian Jenna Wilson, public statements regarding IVF and sex selection, March 2025.

10. Reuters, reporting on U.S.-China competition in artificial intelligence, August 2026.

11. “AI Phobia Is America’s New Consensus,” Financial Times, August 18, 2026.

12. Business Insider, reporting on U.S. data-center expansion, community opposition and resource concerns, August 2026.

13. CBS News, “Elon Musk Tells German Far-Right Supporters There Is ‘Too Much Focus on Past Guilt,’” January 2025.

14. Reuters, “Musk’s Hand Gesture During Trump Inauguration Festivities Draws Scrutiny,” January 21, 2025.

15. Hugh Howey, Wool. Simon & Schuster, 2012.

16. Graham Yost, creator, Silo. Apple TV+, 2023–present.

17. Isaac Asimov, Foundation. Gnome Press, 1951.

18. Douglas Adams, The Hitchhiker’s Guide to the Galaxy. Pan Books, 1979.

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There were other clues I missed. I heard adults talk about “Jewing” somebody down on a price: “I Jewed him from $500 to $300.” I thought they were saying “chewed.” This made no particular sense, but adolescence contains so many things that make no sense that I apparently filed it away with algebra, gym class, and girls.

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One conversation can change a room.

What I didn’t understand was that the people around me had already decided something about me that I hadn’t yet figured out about myself. I was different, although I didn’t look different. I had the same skin color, wore the same clothes, spoke with the same accent. If racism was about how people looked, as I vaguely understood it then, what exactly was the problem with me?

I had learned about racism mostly through Black American history. There were enslaved people, segregation, Rosa Parks, Martin Luther King Jr., drinking fountains, lunch counters, and grainy photographs of white people screaming at Black children trying to enter schools. Racism was awful, but it was also history, or so I thought. Then I graduated from high school in 1981 and discovered, although I didn’t fully understand it until much later, that mine was the last graduating class before the school was “desegregated.”

Desegregated in 1981. Even now, that date astonishes me. The Supreme Court had ruled in Brown v. Board of Education in 1954 that state-mandated racial segregation in public schools violated the Equal Protection Clause.¹ Somehow, twenty-seven years later, my community was still working through the practical implications.

At the time, I barely understood what was happening. My school was absorbed into a much larger system, and the old high school became one of several grade schools. I didn’t know I had been attending school in a community actively trying to remain overwhelmingly white, or that one of my teachers had been involved in resisting desegregation. I certainly didn’t understand my own peculiar place in all of it. As I remember it, among the students making our school somewhat less homogeneous were three Black kids, one Jewish kid, and a student with a physical disability.

I was the Jew. We were apparently diversity.

• 1954: Brown v. Board of Education declares state-mandated school segregation unconstitutional.¹

• 1964: Civil Rights Act.

• 1981: I graduate from a school still confronting desegregation.

• 27 years: Time between Brown and my community apparently receiving the memo.

Two years later, Ronald Reagan’s Secretary of the Interior, James Watt, managed to provide an almost perfect description of this kind of box-checking diversity. Defending the composition of a federal coal-leasing commission in 1983, Watt announced, “I have a black, I have a woman, two Jews and a cripple. And we have talent.”² I remember hearing about it and thinking, That’s my school.

The Black students seemed to find different ways of fitting into a community that was simultaneously trying to prevent more Black students from arriving. One was from Trinidad, which somehow made him “exotic,” as though being from somewhere else put him into a slightly different category (although seeing him with his entire family dancing at a Friday assembly of the white student body was akin to watching a minstrel show.) Another was a big, funny guy whom everybody liked, and humor seemed to function as a kind of passport. The third was also enormously likable and, as I remember him, much more interested in people than school. He was also gay, although he was closeted and none of us talked about it. Given the place and time, that was hardly surprising. Gay people were still routine punch lines.

Looking back, I don’t know how consciously any of us adapted ourselves to that community. Maybe the Trinidadian kid was simply exotic to me. Maybe the funny guy was funny because he was funny. Maybe my gay classmate wasn’t spending every waking moment calculating how to fit in. It would be unfair to rewrite their adolescence for them forty-five years later. What I do remember is how difference seemed to work. People could be different and still be liked, even enormously popular, but certain kinds of difference were easier to accommodate when they arrived wrapped in something reassuring: funny, charming, agreeable, exotic. Other differences were better hidden.

I was doing my own version of fitting in. I wanted people to like me, so I laughed at jokes, tried not to make trouble and, for quite a while, didn’t even recognize when the joke was about me. This is one of the stranger things about childhood: you can be living inside a social system without understanding its rules. You simply begin learning which parts of yourself a particular room welcomes, which parts it tolerates, and which parts are better left outside.

We Didn’t Raise Him This Way

Years later, during my first psychiatric training at the University of Michigan in Ann Arbor, I met a 12-year-old boy whose parents were alarmed because he had suddenly become intensely racist. This wasn’t a kid repeating something stupid he’d heard at school. He had become so distressed by the presence of a Black student in his art class that he managed to get himself moved to another class. His parents were horrified and kept saying, “We didn’t raise him this way.”

I believed them. They were liberal, thoughtful people, and nothing they described suggested a household where racial hatred was being served with dinner. More importantly, their son’s racism wasn’t occurring by itself. He was becoming increasingly suspicious, his thinking was changing, and eventually it became clear that he was developing severe paranoia. We treated him with an antipsychotic medication, and something remarkable happened: the racism disappeared.

I don’t mean the medication transformed a racist child into an enlightened one. Antipsychotics do many useful things, but multicultural education is not generally listed in the package insert. We treated his paranoia, and as the paranoia receded, so did his fixation on the Black child.

I’ve thought about him many times since, not because his case suggests racism is a psychiatric illness. It doesn’t. Most racism has nothing to do with psychosis, and describing prejudice as mental illness would let the rest of us off the hook far too easily. What fascinated me was the order in which things seemed to happen. The boy was frightened first. His mind then needed to explain the fear, and once it went looking for someone to blame, it didn’t have to invent a category. The category was already sitting there waiting for him.

Psychiatrists see this process in an unusually exposed form in paranoia. Something feels terribly wrong, and the mind begins constructing a story to explain why. Depending on the person and the culture surrounding them, the culprit might become the CIA, the neighbors, immigrants, Black people, Jews, Muslims, or whoever happens to be available and believable. The fear can be completely real even when the explanation isn’t.

We prefer to imagine that our minds work in the opposite direction. We gather evidence, think carefully about it, reach a conclusion, and then have an emotional response. Sometimes we even do. But humans are also remarkably good at feeling threatened first and deciding who is responsible afterward. Research on intergroup bias suggests that perceived threat, uncertainty, group identification and social categorization can all intensify the distinction between “us” and “them.”³ That boy hadn’t invented racism, and his parents hadn’t taught it to him. His illness had simply reached into the culture surrounding him and found a ready-made suspect.

His parents were therefore right when they said they hadn’t raised him that way. The problem was that parents aren’t the only people raising children. The rest of us are in the room too.

Who Decides Which Differences Matter?

That boy made me reconsider something I had never understood about my own childhood. I had assumed prejudice began with noticing an obvious difference. Black people looked different from white people, so some white people became racist. It was a crude theory, but I was a kid. What never fit was my own experience because I didn’t look different. The girl searching my head for horns hadn’t discovered anything by looking at me. Somebody had already told her where to look.

That eventually became the more interesting question: who decides which differences matter?

Children notice everything. They notice skin color, accents, clothes, hair, bodies, height, weight, behavior, who smells funny, who has braces and who can’t throw a baseball. Yet we don’t build social hierarchies around every difference children detect. The differences have to acquire meaning, and that meaning comes from somewhere.

Social psychology provides a wonderfully strange demonstration of how little it can take to get this machinery moving. In Henri Tajfel’s famous “minimal group” experiments, people were divided into groups on essentially arbitrary grounds, without an existing history of hostility or meaningful conflict. Even these nearly meaningless categories could produce favoritism toward one’s newly invented in-group.⁴ Later research has repeatedly found versions of this minimal-group effect, although the size and expression of the effect depend on context and culture.⁵

• Minimum requirement for forming an “us”: surprisingly little.⁴

• Long history of conflict required: apparently not.⁴

• Actual biological difference required: no.

• Human ability to turn an arbitrary category into something meaningful: disturbingly efficient.

• Human ability to agree about what the categories mean: considerably worse.

This doesn’t mean human beings are “born racist.” It means something more interesting and, in some ways, more troubling. We appear remarkably prepared to organize ourselves into groups, but the content of those groups is learned. Evolution didn’t put Jew, Black, Muslim, or immigrant into the human brain. Culture fills in the blanks.

Nobody needed to give the girl in my homeroom a formal lecture on antisemitism before she looked for horns. The lesson had already arrived. Nobody needed to explain to my psychiatric patient that a Black child could become the object of his fear. When his frightened mind needed a suspect, the culture had already supplied one. Sometimes the lesson comes from parents, but it can just as easily come from friends, jokes, television, churches, schools, neighborhoods, politicians, or simply noticing who lives where and who seems welcome in which rooms.

This is why I’ve never found “I don’t see race” particularly convincing. Of course we see differences. The more interesting question is what we decide those differences mean. Human beings certainly appear to have an enormous capacity for tribalism, but tribalism and racism aren’t the same thing. The former supplies an astonishingly flexible us-and-them architecture; societies supply the names, histories, stereotypes and hierarchies that fill it. Research on social categorization has spent decades trying to understand both the ease with which these boundaries form and how making identities more complex can sometimes weaken them.⁶

Once those categories acquire a history, they begin accumulating stories: They are dangerous, they are greedy, they are lazy, they are taking something from us, they don’t belong here. The nouns change remarkably easily. The basic story barely changes at all.

Einstein’s Other Life

Albert Einstein understood something about this that we rarely include in the version of him taught in school. We learn Einstein as the man with the wild hair, the violin and E = mc². We learn that he transformed physics, fled Nazi Germany and eventually settled in Princeton. That version is certainly important. Relativity did, after all, rearrange our understanding of the universe.

What I don’t remember learning was what Einstein did after he got here.

Einstein had watched Germany transform Jews from neighbors into an alien population living inside their own country. After Hitler came to power in 1933, Einstein renounced his German citizenship and never returned to live in Germany. His property was seized, his writings were targeted, and Nazi attacks on “Jewish physics” turned one of the world’s most famous scientists into an enemy of the state.⁷ He settled in Princeton and discovered that a country capable of recognizing the insanity of Nazi racial ideology remained remarkably comfortable with its own racial hierarchy.

Einstein became friendly with the singer and activist Paul Robeson, W.E.B. Du Bois, and the great contralto Marian Anderson. When Anderson came to Princeton and was denied lodging at the Nassau Inn because she was Black, Einstein invited her to stay at his home, the beginning of a friendship that lasted for years.⁸ This wasn’t a photo opportunity arranged by somebody’s publicist. It was what Einstein did when a friend wasn’t allowed into the hotel.

In 1946, he traveled to Lincoln University in Pennsylvania, the first degree-granting historically Black college in the United States. He received an honorary degree, lectured on relativity and spoke against racism, calling segregation a “disease of white people” and saying he did not intend to remain quiet about it.⁹

That Einstein barely appeared in my education.

• 1933: Einstein leaves Germany after Hitler comes to power.⁷

• 1946: Visits Lincoln University and publicly condemns American racism.⁹

• 1951: W.E.B. Du Bois is indicted by the federal government; Einstein offers to testify as a character witness.¹⁰

• Amount of this I remember learning in school: approximately none.

• Amount I remember learning about Einstein’s hair: considerably more.

Why?

I don’t mean this as some conspiracy in which America’s school boards secretly agreed to hide the radical Einstein. The simpler explanation may be more interesting. We like geniuses clean. Einstein gave us relativity. Martin Luther King Jr. gave us civil rights. Rosa Parks refused to move to the back of the bus. History becomes much easier to teach when everyone stays in the chapter where we put them.

Einstein didn’t stay in his chapter.

He could easily have decided that antisemitism was his problem. He had certainly earned the right. His country had turned against him because he was Jewish, and he had fled a regime that would murder millions of people for belonging to the same category. Nobody would have blamed him if he had spent the rest of his political life concerned primarily with Jewish survival.

Instead, something about being the target seems to have widened his field of vision. He recognized the machinery. The histories of Nazi antisemitism and American anti-Black racism were obviously not identical, and Einstein didn’t need them to be. He seems to have understood the more basic process by which a society decides that one group belongs less than another.

That may be the part of Einstein’s biography worth teaching alongside relativity.

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What Did We Learn?

That is also the part of Jewish history that has always mattered most to me. The lesson cannot simply be that terrible things happened to Jews, therefore Jews must protect Jews. Of course Jews should protect Jews. My great-aunts and great-uncles had a wonderfully concise summary of several thousand years of Jewish history: “Everyone wants to kill the Jews.”

It wasn’t a particularly nuanced theory of international relations, but history had supplied them with an uncomfortable amount of supporting evidence.

That was part of why I became an ardent Zionist when I was young. Zionism didn’t feel like one more political ideology. It felt like the obvious conclusion of Jewish history. Jews had been expelled from countries they considered home, confined to ghettos, subjected to pogroms and finally murdered industrially by a modern European state. Political Zionism arose in late nineteenth-century Europe in precisely this environment of nationalism, antisemitism and growing arguments that Jews needed political self-determination.¹¹ If Jewish survival always depended on somebody else’s willingness to let Jews remain, then Jews needed one place where nobody else controlled the door.

Israel meant Jews finally had a room from which they could not be expelled.

I still understand that need. I don’t look back at my younger self and think, What an idiot. Quite the opposite. Given the history I knew and the family I came from, it made enormous sense. What has changed is that I now find myself thinking more about the door. What happens when people who desperately needed a room acquire the power to decide who else gets to remain in it?

That question has become increasingly uncomfortable as I watch Israel, Gaza and the wider Middle East. I don’t experience this as a choice between being Jewish and somehow betraying Judaism, or between supporting Israel and wanting Israel to disappear. I experience it as an argument taking place inside the Jewish identity I inherited. If centuries of Jewish history taught me that dehumanization is dangerous, I don’t know how to suspend that lesson when the people being dehumanized aren’t Jews.

There is no magical moral property that comes from having been persecuted. Victims do not automatically become more compassionate people, and collective trauma can leave communities with many legacies, including vigilance, fear and a powerful concern with future threat.¹² Sometimes people who have experienced exclusion become especially sensitive to the exclusion of others. Sometimes people who spent generations worrying about being thrown out become extraordinarily protective of the room once they finally possess the keys.

That isn’t particularly Jewish. It’s particularly human.

• Number of Jews murdered in the Holocaust: approximately six million.¹³

• Phrase that came to symbolize one lesson of the Holocaust: “Never Again.”

• Precise definition of who is included in “Never”: apparently still under discussion.

• Precise definition of who is included in “Again”: same problem.

This is where Einstein seems important to me again. He didn’t have to stop being Jewish to care about Black Americans. Recognizing somebody else’s persecution didn’t diminish his own history. It enlarged what that history meant.

Perhaps that is what experience is supposed to do.

What Is Racism?

When I was young, I thought racism required obvious hatred. A racist was somebody screaming a slur, burning a cross, or refusing to let a Black child enter a school. It was Bull Connor and fire hoses. It was obvious, ugly and performed by people who presumably knew exactly what they were doing.

Those people certainly exist, but after spending a career listening to how human beings actually think, I find the territory before hatred much more interesting. Who gets assumed to be normal? Who gets treated as suspicious? Who has to be charming before being accepted? Who is allowed to make a mistake without proving something about everyone who looks like them? Who gets to be an individual, while someone else becomes the representative of an entire group?

Racism doesn’t necessarily begin with hatred. It can begin much earlier, when a difference becomes a category, the category acquires a story, and the story begins determining who belongs. The sociologist W.E.B. Du Bois famously described the “color-line” as the central problem of the twentieth century, recognizing that racial categories did much more than describe people; they organized power, opportunity and belonging.¹⁴ More than a century later, psychologists and social scientists are still studying how easily categorization can become stereotyping, bias and unequal treatment.

James Baldwin approached the problem from another direction. He repeatedly argued that America’s racial mythology told us at least as much about the people who needed it as about the people it was supposedly describing. Toni Morrison made a related point in her writing about the construction of “the Other”: creating an outsider can help define and stabilize the identity of the insider.¹⁵ The outsider isn’t simply somebody we dislike. Sometimes we need the outsider to help tell us who we are.

That idea takes me straight back to my 12-year-old patient. He was terrified, and his mind needed an outsider. The culture handed him one.

It also takes me back to my school. The community wasn’t simply deciding who Black people were. By fighting desegregation, it was also deciding who it was: white, Protestant, us.

I happened to look like them, which made the whole thing confusing. I had the right skin but apparently the wrong ancestry. The girl touching my head wasn’t examining me to discover whether I was Jewish. She already knew I was Jewish. She was examining me to see whether the story she’d been given about Jews was true.

For years I wondered how she knew I was different when I looked exactly like everyone around me. Eventually I realized that was the wrong question. She hadn’t discovered the difference.

Someone had taught her that it mattered.

The Room

I don’t think the solution to racism is pretending our differences don’t exist. “I don’t see race” has never struck me as much of an accomplishment because, of course, we see differences. Research with children suggests that awareness of socially meaningful racial categories develops early; what children eventually believe those categories mean is shaped by the social world around them.¹⁶ Human beings notice almost everything about one another, frequently including things we would prefer they didn’t.

I am Jewish, and that matters to me. Being Black matters. Being gay matters. Being Palestinian matters. Being Israeli matters. These identities contain histories, families, languages, cultures, wounds, jokes, recipes, memories and communities that people treasure. Making everyone identical isn’t tolerance. It sounds more like a very boring cocktail party.

The problem isn’t that we notice differences, but what we decide those differences mean, and eventually what they permit us to do to another human being. That’s what bothers me about racism and all its relatives. They take the most complicated creatures we know and make them simple. A person becomes a Jew, a Black person, a Muslim, an immigrant, a Palestinian, an Israeli. Eventually even those categories become unnecessarily complicated, and we’re left with the two categories human beings have been remarkably good at understanding for thousands of years: us and them. Once the label becomes more important than the person carrying it, things that would otherwise seem cruel or absurd can begin to sound perfectly reasonable.

Maybe that’s why I keep returning to the idea of the room. I spent part of my childhood trying to figure out how to get into one without realizing there was an entrance requirement. Some people were welcomed because they were funny or charming or useful or exotic. Some could enter but apparently needed to leave a part of themselves outside. Others were never supposed to get through the door at all. I was already inside, more or less, except that occasionally someone would remind me that I wasn’t quite the same as everyone else.

The strange thing is that being on the outside doesn’t necessarily teach us how to behave once we get inside. I wish history worked that neatly. People who have been excluded can become wonderfully sensitive to the exclusion of others, which is what I find so moving about Einstein’s involvement with Black Americans. But they can also become extremely protective of the room once they finally possess the keys. Fear doesn’t automatically disappear when people acquire power. Sometimes it simply gets a better security system.

Being Jewish hasn’t given me an answer to any of this. If anything, my own family cured me fairly early of the idea that a category tells you very much about the person inside it. My great-grandfather was a Lubavitcher rebbe. His children wanted almost nothing to do with his religious world. My great-uncle became a Reform rabbi. My parents wanted me to become a rabbi despite not really raising me to believe in God, and my mother once offered a visiting rabbi a ham and cheese sandwich. I became a psychiatrist. If somebody had asked me to identify the authentic Jew in that collection, I wouldn’t have known where to begin.

What that history did leave me with was a fairly reliable suspicion of certainty about other groups of people. When somebody tells me an entire population doesn’t belong, I want to know why. When I’m told those people are inherently dangerous, incapable of reason, or destined to hate us, I become even more suspicious. And when cruelty toward them is described as unfortunate but necessary for our own safety, the language begins to sound familiar. The groups change, the histories are different, and the suffering should never be lazily equated, but the stories people tell themselves before excluding or hurting other human beings have an uncomfortable family resemblance.

Perhaps that is what Einstein recognized when he arrived in Princeton. The treatment of Black Americans wasn’t the Holocaust, and Einstein never needed it to be. He had seen what happens when a society begins turning neighbors into categories and categories into threats. He recognized enough of the machinery to object when he saw another version of its operating against somebody else. My 12-year-old patient’s illness exposed something similar from the opposite direction. His paranoia needed an explanation for his fear, and the culture offered him a person who could serve as the threat. Once we treated the fear, he no longer needed the story.

That makes me think differently about the girl in my eighth-grade homeroom. For years, I remembered the incident mainly because it was so bizarre. A girl felt my head looking for horns, and I was so clueless that I wasn’t even properly offended. I probably laughed. I was trying to fit in, after all, and laughing was much easier than stopping the conversation to review the history of European antisemitism, about which I knew considerably less than I thought I did.

What I understand now is that neither of us had invented what happened between us. She had inherited a story about Jews, and I had inherited a different story about America. Her story told her that Jews were strange enough that perhaps we really did have horns. Mine told me that racism was something terrible white people had once done to Black people in grainy photographs. We were two kids standing in the same classroom with histories neither of us fully understood.

I spent years wondering how she knew I was different when I looked exactly like everyone else around me. Eventually I realized that this was the wrong question. She hadn’t discovered the difference by looking at me. Somebody had taught her that the difference mattered, just as somebody had taught my community that having more Black children in its schools represented something worth fighting against.

Maybe that is the part of racism I understand differently now. It doesn’t require us to stop seeing differences, and it probably couldn’t if it tried. It requires us to notice what happens after we see them: which differences become interesting, which become frightening, which become jokes, which determine who gets through the door, and which eventually become reasons for keeping somebody outside.

More than forty years later, I can still remember that girl’s hand on the top of my head. I don’t remember exactly what I said afterward, and I doubt either of us gave the encounter much thought once the bell rang. She didn’t find the horns she had been looking for, and I went on trying to fit into a place I didn’t yet understand.

It took me much longer to understand that the important thing wasn’t that I didn’t have horns. It was that somebody had taught her to look for them.

NOTES & SOURCES

1. Brown v. Board of Education of Topeka, 347 U.S. 483 (1954). The Supreme Court held that state laws segregating public schools by race violated the Fourteenth Amendment’s Equal Protection Clause.

2. Dale Russakoff, “Watt’s Off-the-Cuff Remark Sparks Storm of Criticism,” The Washington Post, September 21, 1983. The Congressional Record also preserves the quotation and contemporary reaction to it.

3. Miles Hewstone, Mark Rubin, and Hazel Willis, “Intergroup Bias,” Annual Review of Psychology 53 (2002): 575–604. The review discusses social identity, uncertainty, threat, status, power and other factors associated with intergroup bias.

4. Henri Tajfel, M. G. Billig, R. P. Bundy, and Claude Flament, “Social Categorization and Intergroup Behaviour,” European Journal of Social Psychology 1 (1971): 149–178. The classic minimal-group studies examined discriminatory behavior in the absence of prior hostility or meaningful conflict between groups.

5. Sabine Otten, “The Minimal Group Paradigm and Its Maximal Impact in Research on Social Categorization,” Current Opinion in Psychology 11 (2016): 85–89; see also the cross-cultural meta-analysis of in-group bias.

6. Richard J. Crisp et al., “40 Years of Multiple Social Categorization: A Tool for Social Inclusivity,” European Review of Social Psychology 32 (2021). The review examines how more complex and overlapping social categorization can reduce simple in-group/out-group representations and contribute to “re-humanisation.”

7. Albert Einstein’s departure from Germany followed Hitler’s rise to power in 1933. Einstein renounced his German citizenship and did not return to reside in Germany; Nazi authorities targeted him and his work as part of their campaign against so-called “Jewish physics.” See the American Museum of Natural History’s Einstein exhibition and the Institute for Advanced Study’s Einstein biography.

8. Einstein’s friendship with Marian Anderson and his decision to host her after she was refused lodging in Princeton are documented in accounts of his civil-rights activities, including Fred Jerome and Rodger Taylor, Einstein on Race and Racism (Rutgers University Press, 2005).

9. Einstein visited Lincoln University in May 1946, received an honorary doctorate, lectured on relativity and spoke against racial segregation. Lincoln University’s historical materials document the visit. See Lincoln University’s archival account of Einstein’s visit.

10. When W.E.B. Du Bois was prosecuted in 1951, Einstein offered to appear as a character witness. His intervention and broader relationship with Du Bois are discussed in Jerome and Taylor, Einstein on Race and Racism.

11. For the emergence of modern political Zionism in late nineteenth-century Europe and its relationship to European nationalism and antisemitism, see Walter Laqueur, A History of Zionism (Schocken Books, 2003), and Anita Shapira, Israel: A History (Brandeis University Press, 2012).

12. Research on collective and intergenerational trauma describes complex responses to historical persecution rather than a simple progression from victimization to greater empathy. See Rachel Yehuda et al., “Holocaust Exposure Induced Intergenerational Effects on FKBP5 Methylation,” Biological Psychiatry 80 (2016): 372–380.

13. Approximately six million European Jews were systematically murdered by Nazi Germany and its allies and collaborators during the Holocaust. See the United States Holocaust Memorial Museum’s Holocaust Encyclopedia.

14. W.E.B. Du Bois, The Souls of Black Folk (1903). Du Bois famously wrote that “the problem of the Twentieth Century is the problem of the color-line.”

15. Toni Morrison explored the construction and function of racial “Otherness” throughout her work and explicitly in The Origin of Others (Harvard University Press, 2017).

16. Research in developmental psychology indicates that children perceive and reason about racial categories from an early age, while prejudice and the meanings attached to categories develop through interactions among cognitive development and the surrounding social environment. See Andrew Scott Baron and Mahzarin R. Banaji, “The Development of Implicit Attitudes,” Psychological Science 17 (2006): 53–58; and Kristin Pauker et al., “Race Essentialism and Social Contextual Differences in Children’s Racial Stereotyping,” Child Development 81 (2010): 1799–1813.

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You hurry into the emergency department, frightened and hoping someone recognizes what’s happening before permanent damage occurs. The physician evaluating you has spent years learning how heart attacks present, which tests matter, and which treatments save lives. Every decision is grounded in decades of research and generations of physicians who painstakingly built modern medicine.

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There’s just one problem. The patient who taught medicine what a heart attack looked like probably didn’t look much like you.

That isn’t an indictment of medicine. It’s simply the way science evolved. Every scientific discipline begins by simplifying an impossibly complicated world. Physicists imagine frictionless surfaces. Economists imagine perfectly rational consumers. Medicine, for much of the twentieth century, imagined a reasonably healthy adult man.¹ Researchers weren’t trying to ignore women, children, or older adults; they were trying to answer extraordinarily difficult questions while controlling as many variables as possible. Pregnancy raised understandable ethical concerns after the thalidomide tragedy, hormonal cycles complicated study design, and adult men gradually became the scientific reference point against which everyone else was compared.²

It was a logical place to begin. It simply wasn’t where the story ended.

As physicians accumulated experience, patients kept arriving who didn’t quite fit the picture. Women described heart attacks that looked different from the ones in the textbooks. Children became ill in ways adults didn’t. Patients from different cultures described the same diseases differently. Conditions that had long been dismissed as “stress” or “just anxiety” gradually acquired names, biological explanations, and, perhaps most importantly, legitimacy. Medicine hadn’t failed. It had simply reached the limits of a model that had become too narrow.³

That realization was captured perfectly by Bernadine Healy, the cardiologist and former Director of the National Institutes of Health, in her landmark 1991 essay describing what she called the Yentl Syndrome. Women, she argued, often had to become “honorary men” before receiving the same diagnostic evaluation and treatment as male patients.⁴ Her point wasn’t really about cardiology. It was about what happens whenever we mistake the typical patient for the universal one.

More than a century ago, Will Rogers observed, “It isn’t what we don’t know that gives us trouble; it’s what we know that ain’t so.” Few quotations capture the history of medicine more elegantly. The remarkable story isn’t that previous generations of physicians were wrong. It’s that they kept asking whether yesterday’s assumptions still explained today’s patients. That willingness to question itself has quietly transformed modern medicine. We’ve learned that biological sex influences everything from heart disease to medication metabolism, that children cannot be understood as miniature adults, and that culture, trauma, poverty, loneliness, and chronic stress all shape the way illness develops and is experienced.⁵

The story of modern medicine isn’t one of failure. It’s a story of expanding vision. Some of its greatest advances haven’t come from discovering new diseases. They’ve come from finally seeing the patients who had been there all along.

The Heart Attack That Changed the Textbook

If there was one disease that finally forced medicine to question whether the “average patient” really existed, it was heart disease.

For generations, physicians learned to recognize a heart attack almost instinctively. A middle-aged man develops crushing chest pain that radiates down his left arm, breaks into a cold sweat, and collapses. The image became so familiar that Hollywood adopted it, too. Ask almost anyone to act out a heart attack and chances are they’ll perform exactly that scene.

The problem wasn’t that the picture was wrong. The problem was that it wasn’t complete.

Heart disease has long been the leading cause of death for both men and women, yet much of what physicians understood about heart attacks came from studies conducted primarily in men.⁶ As researchers broadened those studies, they discovered that many women certainly experienced the classic symptoms, but many others arrived describing overwhelming fatigue, nausea, shortness of breath, pain in the jaw, neck, shoulders, or back, or simply the unsettling conviction that something was terribly wrong.⁷ Too often those symptoms were attributed to anxiety, menopause, indigestion, or stress before anyone considered the heart.

As Marianne Legato likes to remind physicians, “Every cell has a sex.”⁸ It sounds almost obvious today, but it represented a profound shift in thinking. Once researchers stopped asking whether women looked like men and started asking how women actually experienced disease, they discovered differences extending far beyond heart attacks. Hormones, immune systems, metabolism, blood vessels, and even responses to medications all turned out to be more complex than medicine had appreciated. The heart hadn’t changed. Our understanding of it had.

As a psychiatrist, I’ve always found another discovery equally fascinating because it reminds us how artificial the boundary between physical and mental illness has always been. For years, physicians viewed depression largely as something that developed after a heart attack. We now know the relationship works in both directions. Depression increases the risk of developing cardiovascular disease, predicts poorer recovery after a heart attack, and increases the likelihood of future cardiac events. Conversely, surviving a heart attack substantially increases the risk of depression and anxiety.⁹ The heart and the brain are in constant conversation through hormones, inflammation, the autonomic nervous system, sleep, and behavior. Cardiology and psychiatry have never been studying separate stories. They’ve been reading different chapters of the same book.

That relationship becomes especially striking in Takotsubo cardiomyopathy, the so-called “broken-heart syndrome,” which occurs overwhelmingly in women.¹⁰ Intense emotional stress can temporarily weaken the heart muscle so dramatically that patients arrive in the emergency department appearing to have a heart attack. For centuries, stories of people dying from grief sounded like poetry. Modern cardiology has shown they can also be physiology.

That may be why Robin Williams‘ observation that “Everyone you meet is fighting a battle you know nothing about” feels so timeless. The woman apologizing for “making a fuss” may be having a myocardial infarction. The man insisting he’s “fine” may be profoundly depressed. The patient sitting quietly in the waiting room is almost always carrying far more than the symptoms we first notice.

• Heart disease remains the leading cause of death among women in the United States.⁶
• Depression approximately doubles the risk of developing coronary heart disease.⁹
• Women continue to experience delays in the recognition and treatment of heart attacks compared with men.⁶

The heart didn’t simply teach medicine that women sometimes have different symptoms. It reminded us that every time we widen our picture of the patient, our picture of disease becomes a little more accurate.

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When Pain Doesn’t Show Up on a Blood Test

If heart disease taught medicine that it had been looking for too narrow a picture of a heart attack, pain forced it to confront an even more unsettling possibility: what if the patient understood the illness before medicine did?

Medicine has always been most comfortable with diseases it can see. A fracture appears on an X-ray. Diabetes announces itself through a blood test. Pneumonia leaves fingerprints on a chest film. Pain is different. It can’t be photographed, biopsied, or measured under a microscope. It exists only in the person experiencing it, leaving physicians to depend on something medicine has always viewed with equal parts respect and skepticism: the patient’s own story.⁷. That uncertainty has consequences.

When symptoms don’t fit the medical model of the moment, it’s often easier to question the patient than the model itself. For generations, women describing pain were more likely than men to have their symptoms attributed to stress, anxiety, or emotional distress before anyone considered that the science itself might be incomplete.⁸ Many spent years moving from one physician to another, accumulating normal laboratory tests while never accumulating an explanation.

Looking back, it’s remarkable how many of those patients turned out to be right.

Endometriosis, affecting roughly one in ten women during their reproductive years, can cause debilitating pelvic pain, infertility, bowel symptoms, and profound fatigue, yet many women still wait years before receiving a diagnosis.¹⁰ Similar stories have unfolded with migraine, autoimmune diseases, postural orthostatic tachycardia syndrome (POTS), myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), fibromyalgia, and hypermobile Ehlers-Danlos syndrome. None of these illnesses suddenly appeared during the past few decades. Medicine simply became better at recognizing what patients had been describing all along.

As a psychiatrist, I’ve always found this especially fascinating because my specialty has often been placed on the wrong side of a false choice. Patients are frequently told an illness is either “medical” or “psychiatric,” as though the brain exists outside the rest of the body. It doesn’t. Anxiety can produce chest pain, dizziness, nausea, palpitations, gastrointestinal distress, and profound fatigue. Depression often hurts physically. Trauma changes the way the nervous system processes pain. At the same time, chronic pain reshapes the brain itself, increasing the risks of depression, anxiety disorders, insomnia, substance use disorders, and suicide.¹¹ The illness influences the brain, the brain influences the illness, and after a while the distinction becomes less useful than the conversation between them.

That’s why I’ve never liked the phrase, “It’s just anxiety.” Sometimes anxiety is the diagnosis. Sometimes it’s the consequence of years spent living with an illness no one else can see. More often, it’s woven into both. Good medicine doesn’t ask whether suffering belongs to the body or the mind. It asks how the two became so intertwined in the first place.

After being diagnosed with breast cancer, Tig Notaro walked onto a comedy stage and opened with four unforgettable words: “Hello. I have cancer.” The audience laughed, then grew quiet, then laughed again. Somehow she transformed one of the worst moments of her life into an evening about connection rather than disease. Physicians try to do something similar. We begin by listening to stories that don’t yet make sense, trusting that today’s mystery may become tomorrow’s diagnosis.

More than a century ago, William Osler offered advice that has only grown wiser with time: “Listen to the patient. He is telling you the diagnosis.”¹¹ Medicine has become extraordinarily sophisticated at sequencing genomes, interpreting MRI scans, and measuring molecules our predecessors never imagined. One of its greatest advances, however, has been rediscovering something much older. Patients often know something is wrong long before science understands why.

• Women account for nearly 80% of patients with autoimmune diseases.¹⁰
• Migraine affects women about three times as often as men.¹⁰
• The average delay in diagnosing endometriosis is still measured in years, not months.¹⁰

Medicine didn’t discover these diseases because they suddenly appeared. It discovered them because it finally learned to listen.

Children Weren’t Just Smaller Adults

As medicine gradually realized that women weren’t simply smaller men, it was forced to abandon another assumption that had survived just as long: children weren’t simply smaller adults.

That seems obvious today, but it wasn’t always. Many medications prescribed to children were originally studied only in adults, with doses adjusted according to body weight and the hope that biology would cooperate.²⁷ Eventually physicians recognized that the real difference wasn’t size. It was development. A child’s brain, immune system, metabolism, hormones, and even the way illness is expressed change continuously throughout childhood.¹²

I learned that lesson during my Child and Adolescent Psychiatry Fellowship at NewYork-Presbyterian Hospital. Like every psychiatry fellow, I had already spent years immersed in adult psychiatry before I was finally “allowed” to learn about children. I’ve often thought that sequence was backwards. We don’t ask pediatric cardiologists to master adult cardiology before they’re permitted to care for children, yet psychiatry has traditionally assumed that understanding the adult naturally prepares us to understand the child. It doesn’t.

I had the privilege of training with several extraordinary attending physicians, each of whom shaped the way I think about patients. One doctor who influenced me most was Jonathan Slater. What made him remarkable wasn’t simply his knowledge. It was the ease with which he entered a child’s world without expecting the child to enter his. He taught me that one of the most common mistakes young psychiatrists make is waiting for children to describe their illnesses the way adults do. They rarely do.

Adults usually arrive with stories. They describe sadness, hopelessness, panic, racing thoughts, or difficulty concentrating. Children communicate through behavior. Depression may look like irritability. Anxiety may masquerade as stomachaches, tantrums, or refusing to go to school. Emotional distress often appears first in the classroom, on the playground, or around the dinner table, long before it appears in words. Once I understood that, I realized I wasn’t learning a younger version of adult psychiatry. I was learning an entirely different language.

That shift in perspective changed far more than child psychiatry. For years, the image of ADHD was the little boy who couldn’t stay in his seat, interrupted everyone, and somehow involved the entire classroom in whatever he was doing. Girls often escaped notice because their symptoms were quieter and easier to hide. Many worked harder, stayed quieter, and exhausted themselves trying to appear organized while privately wondering why everything seemed so much harder for them than everyone else.¹³ Autism followed a similar path. Because much of the early research focused on boys, generations of girls became remarkably skilled at masking, carefully studying facial expressions, rehearsing conversations, and copying classmates until they appeared socially effortless. By the time they came home, many were emotionally depleted.¹⁴

Ironically, the better they became at hiding their struggles, the less likely anyone was to recognize they needed help. Of course, medicine has also had to learn the opposite lesson: not every energetic child has ADHD, just as not every shy child has autism. I was reminded of that recently when an energetic eight-year-old spent our appointment bouncing enthusiastically from one toy to another before proudly announcing, “That’s my ADHD.” Maybe. Or maybe that’s simply what being eight looks like on a Tuesday afternoon. One of the hardest jobs in child psychiatry isn’t recognizing illness. It’s recognizing healthy development.

As John Mulaney once joked, he had “the energy of someone who’s hiding a gun.” Every teacher smiles because they’ve known that child. Every parent has wondered whether that child needs help. Most eventually become perfectly healthy adults. Distinguishing personality, temperament, development, and disease remains one of medicine’s most difficult, and most humbling, responsibilities.

The more medicine learned to see children on their own terms, the more accurate it became. Childhood hadn’t changed. Medicine had finally learned its language.

The Patient Never Arrives Alone

One of the reasons I pursued a Master’s in Public Health was that I wanted to understand illness before patients ever reached my office. Medical school had taught me how diseases work. Public health asked a different question: Why did this particular person become sick while someone else didn’t? That question has quietly shaped the way I’ve practiced medicine ever since.

By the time someone sits across from me and says, “Doctor, something’s wrong,” they aren’t bringing me a diagnosis in isolation. They’re bringing a lifetime. Their biology has already been influenced by where they grew up, what they ate, whether they felt safe as children, whether they had stable housing, meaningful relationships, access to healthcare, chronic stress, trauma, loneliness, or simply enough sleep.¹⁵ Patients don’t arrive carrying only their genes. They arrive carrying their biographies.

Psychiatry makes that impossible to ignore. Two patients with the same diagnosis of depression may describe entirely different illnesses. One talks about overwhelming sadness, another about headaches, exhaustion, stomach pain, or the conviction that something is physically wrong. Neither patient is mistaken. They’re describing the same suffering through the language their brains, bodies, families, and cultures have taught them to speak.¹⁶

For years, medicine framed these questions as nature versus nurture, as though biology and experience were competing explanations. Increasingly, they’ve become impossible to separate. The emerging science of epigenetics suggests that chronic stress, early adversity, nutrition, exercise, sleep, pollution, and social isolation can influence how genes are expressed without changing the DNA itself.¹⁷ Our biology isn’t simply something we’re born with. It’s something our lives continually shape.

That’s one of the reasons I find psychiatry so hopeful. The same brain altered by adversity can also be altered by recovery. Medication, psychotherapy, restorative sleep, exercise, meaningful relationships, purpose, and simply the passage of time don’t merely change how people feel. They change the organ producing those feelings. The brain, like every other organ, responds to the environment in which it lives.

More than 175 years ago, Rudolf Virchow wrote that “Medicine is a social science, and politics is nothing else but medicine on a large scale.”¹⁸ Whether or not one agrees with the second half of that sentence, the first has only become more persuasive. Physicians don’t treat diseases that exist apart from the people who have them. We treat human beings whose biology has been shaped by their experiences, and whose experiences continue shaping their biology every day.

Perhaps that’s been medicine’s greatest evolution. It hasn’t simply become better at understanding diseases. It’s become better at understanding people.

So...Who Was Medicine Built For?

By now, the answer to the title’s question is probably less controversial than it first appeared. Medicine wasn’t built for men so much as it was built starting with men.

That wasn’t the result of a conspiracy or even a conscious decision. It was simply how science evolved. Researchers simplified extraordinarily complicated problems, controlled as many variables as they could, and gradually expanded their understanding as new evidence emerged. For much of the twentieth century, the adult male became medicine’s reference point because he was, at the time, the most practical place to begin.¹⁹

The remarkable part of the story isn’t that medicine started there. It’s that it refused to stay there.

As physicians widened their view, they discovered that women weren’t experiencing “atypical” heart attacks; the textbook had simply been incomplete. Children weren’t speaking an immature version of adult psychiatry but an entirely different developmental language. Patients living with chronic pain weren’t imagining illnesses; they were describing conditions medicine had not yet learned to recognize. Public health reminded us that genes tell only part of the story, while childhood, culture, relationships, trauma, opportunity, and environment spend a lifetime shaping the rest.

Looking back, what impresses me most isn’t how much medicine once missed. It’s how willing it has been to admit that it missed it. Perhaps that’s why Will Rogers‘ observation still feels so modern: “It isn’t what we don’t know that gives us trouble; it’s what we know that ain’t so.” Science has never depended on always being right. It depends on remaining curious enough to question what we think we already know.

Medicine continues to do exactly that. Today’s students will almost certainly discover blind spots that seem obvious a generation from now, just as today’s physicians continue to uncover diseases, treatments, and patterns their teachers could never have imagined.

That’s not a weakness. It’s the scientific method doing exactly what it was designed to do. The greatest advances in medicine haven’t always come from inventing better tests or more powerful medications. Sometimes they’ve come from something much simpler. Looking more carefully at the patient sitting in front of us.

Notes & Sources

1. Caroline Criado Perez. Invisible Women: Data Bias in a World Designed for Men. Abrams Press, 2019.
2. Institute of Medicine. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies. National Academies Press, 1994.
3. Marianne J. Legato, ed. Principles of Gender-Specific Medicine. 3rd ed. Academic Press, 2017.
4. Bernadine Healy. “The Yentl Syndrome.” New England Journal of Medicine. 325(4):274-276, 1991.
5. Institute of Medicine. Exploring the Biological Contributions to Human Health: Does Sex Matter? National Academies Press, 2001.
6. American Heart Association. Heart Disease and Stroke Statistics (most recent scientific statement).
7. Marianne J. Legato. Eve’s Rib: The New Science of Gender-Specific Medicine and How It Can Save Your Life. Harmony Books, 2002.
8. Robert M. Carney & Kenneth E. Freedland. “Depression and Coronary Heart Disease.” Nature Reviews Cardiology. 2017; Diane E. Hoffmann & Anita J. Tarzian. “The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain.” Journal of Law, Medicine & Ethics. 2001.
9. C. Noel Bairey Merz, et al. “Women and Ischemic Heart Disease.” Journal of the American College of Cardiology; reviews of Takotsubo cardiomyopathy in Circulation and the Journal of the American College of Cardiology.
10. Hugh S. Taylor, et al. “Endometriosis.” Nature Reviews Disease Primers.; M.C. Hayter & M.C. Cook. “Updated Assessment of the Prevalence, Spectrum and Case Definition of Autoimmune Disease.” Autoimmunity Reviews.
11. William Osler. Aequanimitas, with Other Addresses to Medical Students, Nurses and Practitioners of Medicine. P. Blakiston’s Son & Co., 1904.
12. Institute of Medicine. Safe and Effective Medicines for Children. National Academies Press, 2012.
13. Stephen P. Hinshaw & Katherine Ellison. ADHD: What Everyone Needs to Know. Oxford University Press, 2016.
14. Sarah Hendrickx. Women and Girls on the Autism Spectrum. Jessica Kingsley Publishers, 2015.
15. Arthur Kleinman. The Illness Narratives: Suffering, Healing, and the Human Condition. Basic Books, 1988.
16. Robert M. Sapolsky. Behave: The Biology of Humans at Our Best and Worst. Penguin Books, 2017.
17. Michael Marmot. The Health Gap: The Challenge of an Unequal World. Bloomsbury, 2015.
18. Rudolf Virchow. Collected Essays on Public Health and Epidemiology (translated selections).
19. National Academies of Sciences, Engineering, and Medicine. Sex and Gender Differences in Health and Disease: Moving from Bench to Bedside. National Academies Press, 2022.

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Long before we understood what a heart attack was, we knew what one looked like. A powerful man clutched his chest and collapsed. Depression meant staring through a rain-soaked window. ADHD belonged to the little boy who couldn’t stay in his seat. Autism had the face of Rain Man. Eating disorders belonged to painfully thin teenage girls pushing food around a dinner plate. These scenes became so familiar that they stopped feeling like fiction. They became expectations.

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Stories have always helped human beings make sense of a complicated world. They give us recognizable characters, familiar conflicts, and satisfying endings. As Joan Didion wrote, “We tell ourselves stories in order to live.”¹ The stories change over time, but their purpose remains the same: they help us understand ourselves.

Movies are among the most influential stories we tell. They shape what heroes look like, what villains look like, what families look like, and, often without our realizing it, what illness looks like. That influence helps explain why debates over films become so passionate. Whether the argument concerns race, disability, sexuality, historical accuracy, or gender, the disagreement is rarely just about entertainment. Beneath it lies a shared assumption: stories change people. As Heather Cox Richardson has argued throughout her work, Americans have always understood themselves through the stories they tell about who they are and who they hope to become.² Hollywood has become one of our most influential storytellers.

Medicine tells stories, too.

Every diagnosis begins with one. A patient describes what happened, when it began, and how life has changed. Physicians compare that story with thousands of others learned through experience, research, and training. For much of the twentieth century, however, many of those stories came from remarkably similar patients, most often adult men. The resulting textbook descriptions became the “classic” presentations taught to generations of physicians. They were enormously valuable, but they were never meant to represent everyone.

As research broadened to include women, children, older adults, and more diverse populations, medicine discovered something both humbling and liberating. Heart attacks didn’t always begin with crushing chest pain. ADHD wasn’t confined to restless little boys. Autism extended far beyond the character audiences met in Rain Man. Invisible illnesses often looked invisible because medicine hadn’t yet learned where to look. Depression and eating disorders turned out to have far more faces than anyone had imagined.

In 1991, Dr. Bernadine Healy, the first woman to direct the National Institutes of Health, gave one of these blind spots a memorable name. In describing the “Yentl Syndrome,” she argued that women often had to present like men before receiving the same diagnostic attention.³ Her observation reached far beyond cardiology. Again and again, medicine discovered that the patient who didn’t fit the textbook wasn’t unusual. The textbook itself needed revision.

The chapters that follow revisit some of Hollywood’s most memorable medical stories, not because the movies got medicine wrong, but because they faithfully reflected what medicine believed at the time. In every case, the most important plot twist came later, when patients arrived with stories that refused to fit the script.

Cardiology 101: The Man Who Grabbed His Chest

If Hollywood has an iconic medical scene, it belongs to The Godfather.

Vito Corleone is walking through his tomato garden with his grandson when he suddenly stops. His hand moves instinctively to the center of his chest. He gasps, stumbles, and collapses among the tomato vines. It is one of the most recognizable heart attacks in movie history, and audiences understand exactly what has happened before anyone speaks. We have seen the same scene repeated for decades, in films, television dramas, and commercials, until it has become less a movie scene than a shared cultural memory.

The scene worked because it reflected what medicine believed.

For much of the twentieth century, the textbook heart attack was based largely on studies of men. Crushing substernal chest pain radiating into the left arm became the classic presentation because it genuinely described many of the patients physicians were treating. Medical students learned the pattern, doctors recognized it, and screenwriters borrowed it because audiences recognized it as well.

The picture began to change only after researchers started asking a different question: What if the patients we had been studying weren’t representative of all patients?

Television unintentionally captured another important lesson. One of the central storylines in The Sopranos follows Tony Soprano’s panic attacks. They are frightening because they resemble heart attacks so closely. Chest pain, shortness of breath, dizziness, sweating, palpitations, and an overwhelming fear of dying belong to both conditions. Every emergency physician knows the first task isn’t deciding whether someone is anxious. It is determining whether the heart is in danger.⁵

The relationship extends beyond the emergency department. Depression increases the risk of cardiovascular disease, while anxiety, depression, and post-traumatic stress commonly follow a heart attack. Dr. Nanette Wenger, whose career transformed the understanding of cardiovascular disease in women, has spent decades reminding physicians that diseases never affect organs in isolation. They affect people. Heart disease remains the leading cause of death among American women, exceeding the combined deaths from all forms of cancer.⁶

The familiar Hollywood heart attack never disappeared. Medicine simply realized it had mistaken one common story for the whole story.

Hollywood vs. Reality

• Hollywood: Heart attacks happen to middle-aged men clutching their chests.

Reality: Heart disease is the leading cause of death in women, whose symptoms often differ substantially from men’s.

• Hollywood: Every heart attack begins with crushing chest pain.

Reality: Fatigue, nausea, indigestion, jaw pain, back pain, dizziness, or shortness of breath may be the dominant symptoms, particularly in women.

• Hollywood: Chest pain is probably anxiety.

Reality: Panic attacks and heart attacks overlap enough that physicians must first rule out a cardiac emergency.

• Hollywood: Opening the blocked artery ends the story.

Reality: Depression, anxiety, and PTSD commonly follow myocardial infarction and significantly influence recovery.

Psychiatry 101: The Hyperactive Little Boy

For generations, if Hollywood wanted audiences to recognize a child with ADHD, it knew exactly whom to cast.

He couldn’t stay in his seat. He interrupted the teacher, forgot his homework, talked nonstop, acted before thinking, and somehow managed to turn every ordinary day into a small catastrophe. Dennis the Menace, Problem Child, Bart Simpson, and countless sitcom troublemakers (or Calvin from Calvin and Hobbes, not a TV series or movie) weren’t written as medical case studies, but together they created a character everyone recognized. Even people who had never heard the term Attention-Deficit/Hyperactivity Disorder understood the type.

Medicine recognized him, too.

The earliest research on ADHD focused largely on boys because they were the children most likely to be referred for evaluation. They disrupted classrooms, frustrated parents, and drew attention wherever they went. Hyperactivity and impulsivity naturally became the defining features of the disorder because those were the symptoms physicians encountered most often. The diagnosis fit the patients medicine was seeing. The children who didn’t fit the diagnosis often disappeared into the background.

Many girls with ADHD were not disruptive. They forgot assignments, drifted through conversations, stared out classroom windows, misplaced schoolwork, and quietly struggled to keep up with classmates who seemed effortlessly organized. Teachers often described them as bright but inconsistent, anxious, or simply unmotivated. Years later, many women would look back on those same report cards and recognize symptoms no one had ever named. As Dr. Patricia Quinn, whose work transformed the understanding of ADHD in girls, has argued, these patients weren’t overlooked because they lacked ADHD. They were overlooked because medicine had learned to recognize only one version of it.⁷

The story became even more complicated when those children grew up. For years, ADHD was considered a childhood disorder, the assumption being that children eventually outgrew it. Instead, many simply outgrew the stereotype. The restless little boy became the physician who misplaced his stethoscope, the attorney who missed filing deadlines, the engineer buried beneath unfinished projects, or the parent who forgot every school permission slip despite caring deeply about their children. Success often disguised ADHD far more effectively than it cured it.

Research eventually shifted from asking why some children couldn’t pay attention to asking how the brain organizes attention in the first place. Increasingly, ADHD came to be understood as a disorder of executive functioning, affecting planning, organization, working memory, emotional regulation, and the ability to direct attention intentionally rather than reactively. As Dr. Russell Barkley has written, the problem is rarely knowing what to do. It is consistently doing what you already know.⁸

Nearly half of children diagnosed with ADHD today are girls, and millions of adults have finally found an explanation for struggles they once blamed on laziness, carelessness, or a lack of discipline.⁹ The hyperactive little boy never disappeared. He simply turned out to have a much larger class than anyone imagined.

Hollywood vs. Reality

• Hollywood: ADHD is the little boy who can’t stay in his seat.

Reality: ADHD affects girls and boys, women and men, often presenting very differently across age and sex.

• Hollywood: Quiet children don’t have ADHD.

Reality: Many children, particularly girls, present primarily with inattentiveness rather than hyperactivity.

• Hollywood: People outgrow ADHD.

Reality: ADHD frequently persists into adulthood, although its appearance often changes over time.

• Hollywood: ADHD is simply an attention problem.

Reality: ADHD primarily affects executive functioning, including planning, organization, working memory, emotional regulation, and self-management.

Neurology 101: The Rain Man Myth

Few films have influenced public understanding of a medical condition more than Rain Man.

When it premiered in 1988, many Americans were encountering autism for the first time. Dustin Hoffman’s Raymond Babbitt was brilliant with numbers, depended on routine, interpreted language literally, and experienced the world with an intensity that fascinated audiences. Rain Man won four Academy Awards, but its greater achievement was changing the public conversation. Autism was no longer something to fear or ridicule. It became a story people could empathize with.

For many viewers, however, Raymond Babbitt didn’t simply represent one autistic man. He became autism.

Hollywood rarely challenged that image. Temple Grandin celebrated extraordinary visual thinking. The Good Doctor portrayed a gifted surgeon whose autism was inseparable from his remarkable abilities. Even Sheldon Cooper from The Big Bang Theory came to be viewed by many audiences through a similar lens. Different characters told essentially the same story: autism was obvious, exceptional, overwhelmingly male, and easy to recognize.

Medicine once believed much the same thing.

The earliest description of autism came in 1943, when Dr. Leo Kanner described eleven children with strikingly similar social and communication differences.¹ As awareness grew, clinicians continued diagnosing primarily boys because they were the children most often referred for evaluation. Diagnostic criteria naturally evolved around those patients, making it increasingly easy to recognize children who fit the established picture and increasingly difficult to recognize those who did not.

Many girls learned to hide in plain sight.

Rather than standing apart socially, they often became careful observers, studying facial expressions, rehearsing conversations, imitating classmates, and memorizing social rules that seemed to come naturally to everyone else. Many described feeling like actors performing a role rather than participants in the conversation. The effort could be exhausting, but it often delayed recognition for years. Some women were not diagnosed until adulthood, occasionally only after one of their own children underwent an autism evaluation. As Dr. Lorna Wing, whose work transformed the modern understanding of autism, argued decades ago, autism is better understood as a spectrum than as a single condition.²

That change in perspective transformed the diagnosis itself. Today, autism encompasses people who require lifelong support as well as physicians, artists, engineers, teachers, scientists, and parents. Many also live with ADHD, anxiety disorders, depression, obsessive-compulsive disorder, sleep disorders, or sensory differences that influence everyday life as much as autism itself. The diagnosis became more common not because autism suddenly appeared, but because medicine finally recognized people it had been overlooking.

Today, approximately one in thirty-one American children is identified as being on the autism spectrum, a dramatic increase from previous generations.³ Much of that change reflects broader diagnostic criteria, earlier identification, greater awareness, and recognition of presentations that earlier generations of physicians simply weren’t trained to see.

Rain Man introduced the world to autism. Patients introduced medicine to the spectrum.

Hollywood vs. Reality

• Hollywood: Autism looks like Rain Man.

Reality: Autism encompasses an enormous range of personalities, abilities, strengths, and support needs.

• Hollywood: Autism usually comes with extraordinary genius.

Reality: Some autistic people have exceptional abilities, but most display the same range of intelligence found throughout the general population.

• Hollywood: Autism is mostly a disorder of boys.

Reality: Girls and women are frequently underdiagnosed because they often present differently and learn to camouflage their differences.

• Hollywood: Autism exists by itself.

Reality: ADHD, anxiety, depression, OCD, sleep disorders, sensory differences, and tic disorders commonly accompany autism and often shape daily functioning as much as autism itself.

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Internal Medicine 101: The Illness Nobody Could See

If House taught audiences anything, it was that every illness leaves clues.

A patient collapses. Blood tests reveal something unexpected. An MRI uncovers a hidden lesion. Dr. Gregory House studies the evidence, makes one final leap of intuition, and the mystery is solved before the closing credits. The audience is never left wondering who is sick because illness announces itself in ways that cameras can capture.

Real medicine is often much quieter.

Some of the most disabling illnesses leave remarkably little to see. A woman with endometriosis may spend years trying to convince physicians that her pain is more than “bad periods.” Someone with lupus can look perfectly healthy while an immune system quietly attacks the body’s own tissues. A patient with migraine may disappear into a dark room for days, only to return looking completely well. A young adult with Postural Orthostatic Tachycardia Syndrome (POTS) may become dizzy or faint simply by standing, while someone with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) may find that a trip to the grocery store requires the rest of the day—or longer—to recover.¹³

These illnesses have little in common biologically. What they share is the burden of invisibility.

Because patients often appear healthy, they are frequently treated as though they are healthy. Laboratory studies may be normal. Imaging may reveal nothing remarkable. Friends begin to wonder whether the illness is exaggerated. Employers question repeated absences. Family members encourage patients to “push through it.” Even physicians can become trapped by the assumption that if tests fail to reveal a disease, the problem must lie elsewhere.

Medicine has encountered this lesson repeatedly.

Endometriosis often required surgery before physicians accepted that it existed. POTS remained unfamiliar to many clinicians until the past two decades. ME/CFS spent years dismissed as little more than chronic fatigue despite mounting evidence of abnormalities involving the immune system, metabolism, and the autonomic nervous system. As Dr. Anthony Komaroff, who has devoted much of his career to ME/CFS research, has argued, scientific understanding often advances years before public perception catches up.¹³

The COVID-19 pandemic reminded both physicians and the public how much remains to be learned. Millions of people developed persistent fatigue, brain fog, dizziness, exercise intolerance, and autonomic symptoms after recovering from COVID-19. Long COVID did not invent invisible illness. It simply introduced millions of people to experiences patients with ME/CFS, POTS, migraine, autoimmune disease, fibromyalgia, and endometriosis had been describing for decades.

Perhaps the most important lesson is also the simplest. Patients often describe diseases years before medicine develops the tools to measure them. Listening, in those moments, becomes every bit as important as testing.

Women with endometriosis wait an average of seven to ten years before receiving a diagnosis.¹⁴ That statistic says as much about the history of medicine as it does about the disease itself.

Hollywood vs. Reality

• Hollywood: Serious illness is obvious.

Reality: Many of the most disabling illnesses leave few outward signs despite profoundly affecting everyday life.

• Hollywood: Normal tests mean nothing is wrong.

Reality: Patients often describe diseases years before medicine develops reliable ways to measure them.

• Hollywood: It’s either physical or psychological.

Reality: Physical and psychological illnesses frequently coexist, and uncertainty should never be mistaken for absence.

• Hollywood: Once the diagnosis is made, the story is over.

Reality: For many chronic illnesses, receiving a diagnosis is the beginning rather than the end of the story.

Psychiatry 101: The Dangerous Depressed Person

If Hollywood has a favorite psychiatric illness, it is depression.

The images are instantly recognizable. A character sits alone in a dark apartment. The curtains remain closed. Dishes pile up in the sink. Rain falls outside the window while the soundtrack slows to a whisper. Whether audiences were watching Ordinary People, The Hours, or A Star Is Born, they were never expected to wonder who was depressed. The illness announced itself visually, long before anyone spoke the diagnosis.

Psychiatrists rarely have that luxury.

Many people with severe depression continue going to work every morning. They raise children, perform surgery, argue cases in court, teach classrooms, coach soccer, laugh with friends, and answer emails. Their lives often appear perfectly ordinary. Only in the privacy of an office do they describe months of exhaustion, hopelessness, guilt, insomnia, or the quiet realization that nothing in life feels rewarding anymore. Families are frequently stunned. “They seemed fine,” they say, discovering that suffering often hides behind competence.

Medicine has gradually learned that depression wears many disguises. Sadness is only one of them. Some patients become irritable. Others complain primarily of headaches, chronic pain, stomach problems, poor concentration, or overwhelming fatigue. Many first seek help from a primary care physician rather than a psychiatrist because they believe something must be physically wrong. Sometimes something is. Often both conditions exist together. As Dr. Kay Redfield Jamison, who has written candidly about living with bipolar disorder while becoming one of psychiatry’s most respected scholars, has observed, mood disorders have a remarkable ability to hide in plain sight.¹⁵

Hollywood has also struggled with suicide. Movies often suggest that people who die by suicide are obviously desperate or leave unmistakable clues. Sometimes they do. Many times they do not. As psychologist Dr. Thomas Joiner has argued, suicide usually develops from the convergence of unbearable psychological pain, hopelessness, social disconnection, and an acquired ability to overcome the instinct for self-preservation.² The tragedy is that many people become increasingly skilled at concealing their suffering precisely when they are at greatest risk.

Jane Fonda has often spoken about the importance of human connection and community in healing. That observation captures something medicine has repeatedly confirmed. Medication and psychotherapy save lives, but recovery also depends on relationships. Depression isolates people by convincing them they are alone when, in fact, connection may be exactly what they need most.

Nearly one in five American adults will experience a depressive disorder during their lifetime.¹⁶ The challenge has never been recognizing depression when it looks like the movies. The challenge is recognizing it when it doesn’t.

Hollywood vs. Reality

• Hollywood: Depression is obvious.

Reality: Many people with severe depression continue working, parenting, and socializing while experiencing profound internal suffering.

• Hollywood: You can always recognize someone at risk for suicide.

Reality: Suicide risk is complex, and many people who die by suicide show few outward signs.

• Hollywood: Depression always looks like sadness.

Reality: Irritability, insomnia, chronic pain, poor concentration, fatigue, and emotional numbness may be more prominent than sadness.

• Hollywood: If someone is smiling, they can’t be seriously depressed.

Reality: Outward functioning often bears little relationship to the severity of depression.

Nutrition 101: The Girl Who Wouldn’t Eat

If Hollywood has a defining image of an eating disorder, it is the teenage girl who refuses dinner.

She pushes food around her plate, cuts it into impossibly small pieces, and insists she has already eaten. Her worried parents plead with her to take one more bite. Later, she stands in front of a mirror unable to see what everyone else sees. Films such as To the Bone and documentaries like Thin helped audiences understand that anorexia nervosa is a devastating psychiatric illness rather than vanity or a desperate search for attention. They replaced judgment with compassion.

They also left us with a remarkably specific picture of who develops eating disorders.

For many years, medicine shared that picture. Eating disorders were thought to affect primarily thin, adolescent girls because they were the patients most likely to be recognized, hospitalized, and studied. Like so many conditions in this article, the earliest descriptions reflected the patients physicians saw most often. The stereotype became so familiar that it influenced not only the public, but medicine itself.

As researchers widened their view, the diagnosis changed dramatically. Boys and men develop anorexia and bulimia. Adults develop eating disorders, sometimes for the first time in middle age. Binge Eating Disorder is now recognized as the most common eating disorder in the United States, while Avoidant/Restrictive Food Intake Disorder (ARFID) has shown that severe nutritional impairment may have little to do with body image. Some patients avoid food because of overwhelming sensory sensitivities, fear of choking, fear of vomiting, or previous traumatic experiences rather than any desire to lose weight.¹⁷

Body size proved equally misleading. Patients with anorexia are not always underweight, particularly if they began at a higher weight before becoming ill. Others struggle with severe eating disorders while living in larger bodies, making their illness easier to overlook because they don’t resemble the image everyone expects. As Dr. Hilde Bruch, whose work transformed the understanding of anorexia nervosa, argued decades ago, eating disorders are rarely about food itself. Food becomes the language through which anxiety, perfectionism, trauma, shame, and the need for control are expressed.¹⁸

Perhaps no diagnosis illustrates the danger of stereotypes more clearly than ARFID. Many children and adults with the disorder desperately want to eat normally but find certain textures, smells, tastes, or fears so overwhelming that eating itself becomes distressing. Looking at them through the lens of anorexia obscures an entirely different illness requiring an entirely different approach.

Nearly one in ten Americans will experience an eating disorder during their lifetime.¹⁹ The teenage girl at the dinner table was never the whole story. She was simply the character we noticed first.

Hollywood vs. Reality

• Hollywood: Eating disorders affect thin teenage girls.

Reality: Eating disorders occur in children, adolescents, adults, men, women, athletes, and people of every body size.

• Hollywood: You can recognize an eating disorder by looking at someone.

Reality: Serious eating disorders often occur in people whose weight appears average or above average.

• Hollywood: Eating disorders are all about wanting to be thin.

Reality: Anxiety, perfectionism, obsessive thinking, trauma, and sensory differences frequently play central roles.

• Hollywood: Recovery is simply gaining weight.

Reality: Nutritional recovery is essential, but lasting recovery also requires treating the psychological illness beneath the eating behavior.

Graduation Day

Hollywood never intended to become a medical school. It simply told stories. Like every storyteller, it relied on recognizable characters and familiar plots. A heart attack had to look like a heart attack. Depression had to look like depression. Audiences needed to recognize the diagnosis before the next scene began. The simplification wasn’t a flaw. It was how stories worked.

Medicine was doing something remarkably similar.

Textbooks distilled thousands of patient encounters into patterns that could be taught to the next generation of physicians. Those patterns saved lives, but they also reflected the limits of what medicine knew at the time. The “classic patient” was never meant to represent everyone. Over time, however, it often came to.

The past several decades have quietly rewritten those stories. Women described heart attacks that looked nothing like the movies. Girls with ADHD slipped through school unnoticed. Adults discovered they had spent decades masking autism. Patients with invisible illnesses continued suffering despite normal tests. Depression hid behind successful careers, and eating disorders appeared in people who looked nothing like the characters audiences had learned to expect.

Eventually, the exceptions stopped looking like exceptions. They looked like humanity.

That may be one of science’s greatest strengths. Unlike stories, science is expected to change. Every generation inherits the best evidence available, questions it, tests it, and revises it. Medicine advances not because it avoids uncertainty, but because it welcomes evidence that proves yesterday’s certainty incomplete.

Stories evolve, too.

Every generation revisits old stories, adding voices that were overlooked and questioning assumptions that once seemed obvious. Some people celebrate those changes. Others resist them. The debates themselves reveal something important: we instinctively understand that stories matter because stories shape expectations. They influence what we notice, what we ignore, and sometimes what we believe is even possible.

The same has always been true of medicine.

More than a century ago, Sir William Osler advised physicians to “listen to the patient; he is telling you the diagnosis.”²⁰ It remains one of the wisest sentences ever written about medicine because it reminds us that every scientific advance begins with someone whose story doesn’t fit the existing explanation.

Hollywood gave us unforgettable characters.

Our patients reminded us that real people are always more complicated than the script.

Notes and Sources

1. Joan Didion. The White Album. New York: Simon & Schuster; 1979.
2. Heather Cox Richardson. Democracy Awakening: Notes on the State of America. New York: Viking; 2023.
3. Bernadine Healy. “The Yentl Syndrome.” New England Journal of Medicine. 1991;325:274-276.
4. Bernadine Healy. “The Yentl Syndrome.” New England Journal of Medicine. 1991; Mehta LS, Beckie TM, DeVon HA, et al. “Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association.” Circulation. 2016.
5. Fleet RP, Dupuis G, Marchand A, et al. “Panic Disorder in Emergency Department Chest Pain Patients.” American Journal of Medicine. 2000.
6. American Heart Association. Heart Disease and Stroke Statistics—2025 Update. Circulation. 2025; Levine GN, Cohen BE, Commodore-Mensah Y, et al. “Psychological Health, Well-Being, and the Mind-Heart-Body Connection.” Circulation. 2021; Wenger NK. Selected reviews on women and coronary heart disease.
7. Patricia O. Quinn. “Attention-Deficit/Hyperactivity Disorder in Girls and Women.” Current Psychiatry Reports. 2008.
8. Russell A. Barkley. Executive Functions: What They Are, How They Work, and Why They Evolved. Guilford Press; 2012; Faraone SV, Banaschewski T, Coghill D, et al. “Attention-Deficit/Hyperactivity Disorder.” Nature Reviews Disease Primers. 2021.
9. Centers for Disease Control and Prevention. ADHD Data and Statistics; National Institute of Mental Health. Attention-Deficit/Hyperactivity Disorder.
10. Leo Kanner. “Autistic Disturbances of Affective Contact.” The Nervous Child. 1943.
11. Lorna Wing. “The Autistic Spectrum.” The Lancet. 1997; Lord C, Brugha TS, Charman T, et al. “Autism Spectrum Disorder.” The Lancet. 2020; Mandy W. “Social Camouflaging in Autism.” Autism. 2018.
12. Centers for Disease Control and Prevention. Autism and Developmental Disabilities Monitoring (ADDM) Network Surveillance Reports.
13. Anthony L. Komaroff. “Advances in Understanding the Pathophysiology of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.” JAMA. 2019; Raj SR. “Postural Tachycardia Syndrome.” Circulation. 2013; Goadsby PJ, Holland PR, Martins-Oliveira M, et al. “Migraine.” Nature Reviews Disease Primers. 2017.
14. World Health Organization. Endometriosis Fact Sheet; American College of Obstetricians and Gynecologists. Practice Bulletin: Endometriosis.
15. Kay Redfield Jamison. An Unquiet Mind. Knopf; 1995; Joiner T. Why People Die by Suicide. Harvard University Press; 2005.
16. National Institute of Mental Health. Major Depression; Substance Abuse and Mental Health Services Administration (SAMHSA). National Survey on Drug Use and Health.
17. Cynthia M. Bulik, et al. “The Hidden Burden of Eating Disorders.” The Lancet. 2020; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). 2022.
18. Hilde Bruch. The Golden Cage: The Enigma of Anorexia Nervosa. Harvard University Press; 1978; Thomas JJ, Eddy KT. Cognitive Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder. Cambridge University Press; 2019.
19. Deloitte Access Economics. The Social and Economic Cost of Eating Disorders in the United States. 2020; STRIPED (Strategic Training Initiative for the Prevention of Eating Disorders). Harvard T.H. Chan School of Public Health. National Eating Disorder Statistics.
20. William Osler. Aequanimitas, with Other Addresses to Medical Students, Nurses and Practitioners of Medicine. Philadelphia: P. Blakiston’s Son & Co.; 1904.

Films and Television Referenced

• The Godfather (1972)

• The Sopranos (1999–2007)

• Dennis the Menace (1993)

• Problem Child (1990)

• The Simpsons (Bart Simpson, 1989–present)

• Rain Man (1988)

• Temple Grandin (2010)

• The Good Doctor (2017–2024)

• The Big Bang Theory (2007–2019)

• House, M.D. (2004–2012)

• Ordinary People (1980)

• The Hours (2002)

• A Star Is Born (2018)

• To the Bone (2017)

• Thin (2006 documentary)

(Movie examples are illustrative rather than exhaustive and are intended to reflect widely recognized cultural portrayals rather than critique individual films.)

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Years ago, a patient walked into my office carrying a stack of medical records. Neurology had ruled out multiple sclerosis. Rheumatology had ruled out lupus. Cardiology had ruled out heart disease. Gastroenterology had ruled out inflammatory bowel disease. One by one, each specialist assured her the problem wasn’t in their field and suggested she see a psychiatrist.

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By the time she reached me, she no longer heard, “We don’t know.”

She heard,

“It’s all in your head.”

She wasn’t relieved.

She was terrified.

“If all the tests are normal,” she asked, “why do I feel so awful?”

It’s one of the hardest questions in medicine because sometimes the most honest answer is simply,

“I believe you.”

“I don’t know...yet.”

Medicine is built on answers. We spend years learning diseases, medications, anatomy, laboratory tests, and imaging, yet some of the patients we remember most are the ones who leave without a diagnosis. Human beings don’t tolerate uncertainty very well. Patients want explanations. Doctors want explanations. Even insurance companies insist on explanations because the computer won’t accept “We’re not sure” as a diagnosis.

So when certainty disappears, medicine does what people have always done. It tells itself a story. Sometimes those stories become breakthroughs. Sometimes they become blindfolds. Instead of explaining the illness, we begin explaining the patient.

Anxious. Emotional. Dramatic. Attention-seeking. Hysterical.

As Atul Gawande (surgeon and author) writes, *”Medicine’s ground state is uncertainty. And wisdom—for both patients and doctors—is defined by how one copes with it.”²

History suggests we’ve never been especially comfortable with uncertainty.

• Before Helicobacter pylori, ulcers were largely blamed on stress.³
• Before EEGs, epilepsy was blamed on insanity—or demons.⁴
• Endometriosis still takes years, on average, to diagnose.⁵

Perhaps medicine’s greatest mistake isn’t that it sometimes fails to understand an illness. It’s that, every so often, it mistakes its uncertainty for the patient’s diagnosis.

The Graveyard of “It’s All in Your Head”

History has a remarkable way of humbling medicine. Again and again, illnesses once dismissed as psychological quietly migrate into neurology, immunology, infectious disease, or genetics. Not because the patients changed, but because science finally developed the tools to see what had been there all along.

Peptic ulcers may be the best-known example. For decades, physicians blamed stress, personality, and ambitious lifestyles until Barry Marshall (physician) and Robin Warren (pathologist) demonstrated that many ulcers were caused by Helicobacter pylori. The idea seemed so absurd that Marshall swallowed the bacteria himself to prove it. Twenty years later, he accepted the Nobel Prize.⁶

The story repeated itself. Multiple sclerosis was once dismissed by some physicians as “hysterical paralysis” before MRI scans revealed inflammatory lesions throughout the brain.⁷ Epilepsy spent centuries blamed on demons, insanity, or weak character before scientists learned to record the brain’s electrical activity.⁸ Parkinson’s disease, too, was once viewed through a psychological lens before its biological basis became clear.⁹

Today, the names are different, but the uncertainty feels familiar. Patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), fibromyalgia, hypermobile Ehlers-Danlos syndrome, postural orthostatic tachycardia syndrome (POTS), and long COVID often spend years collecting normal test results instead of answers.¹⁰ Some of these illnesses will undoubtedly be understood differently twenty years from now. History doesn’t tell us which ones.

It simply reminds us not to confuse the limits of today’s technology with the limits of today’s biology.

• Nobel Prize awarded for the discovery of Helicobacter pylori: 2005.¹¹
• Americans estimated to have ME/CFS: 1–3 million.¹²
• Nearly every generation has had diseases medicine first explained psychologically before understanding them biologically.

As Lewis Thomas (physician and essayist) wrote, *”The greatest obstacle to discovery is not ignorance—it is the illusion of knowledge.”*¹³. Medicine doesn’t become wiser because it stops making mistakes. It becomes wiser because it learns to recognize them.

Maybe the Body Never Read the Textbook

Medicine likes categories. Neurology studies the brain. Immunology studies the immune system. Rheumatology studies joints. Psychiatry studies thoughts, emotions, and behavior. The body has never been nearly so tidy.

Patients with ME/CFS, fibromyalgia, hypermobile Ehlers-Danlos syndrome, POTS, and long COVID often don’t fit comfortably into any one specialty. Their symptoms spill across organ systems, leaving each specialist with one piece of a much larger puzzle.¹⁴. Perhaps that’s because we’ve been asking the wrong question.

For generations, medicine has tried to decide whether an illness is physical or psychological. Increasingly, modern biology suggests the answer is often both. The brain, immune system, endocrine system, and autonomic nervous system are in constant conversation. Chronic stress changes immunity. Inflammation affects mood. Infection alters cognition. Childhood trauma leaves measurable biological fingerprints decades later.¹⁵⁻¹⁸ The deeper scientists look, the harder it becomes to draw a bright line between mind and body.

This doesn’t mean every mysterious illness has a hidden biological cause waiting to be discovered, nor that every psychiatric illness will someday be diagnosed with a blood test. It simply means the body functions as one interconnected system, while medicine has traditionally studied it one organ at a time.

• Stress changes biology, and biology changes how we experience stress.¹⁹
• The brain is not separate from the body. It is part of the body.
• The line between “mental” and “physical” grows blurrier every year.

As Siddhartha Mukherjee (physician and author) writes, *”The boundaries that separate disciplines are often artificial.”*²⁰. Perhaps medicine’s next great breakthrough won’t come from discovering another disease. Perhaps it will come from discovering that many of the boundaries between diseases never existed at all.

The Most Honest Diagnosis

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Every generation of physicians wonders how the generation before could have been so wrong. How could they blame ulcers on stress, epilepsy on demons, or women with chronic pain on “hysteria”? A century from now, physicians will almost certainly ask the same question about us.

Somewhere today, patients are living with illnesses medicine doesn’t yet understand. Some will eventually be explained by genes, infections, immune dysfunction, environmental exposures, or mechanisms nobody has yet imagined. Others may prove more complicated than any single diagnosis can capture.

The patients won’t change. Our understanding will.

That’s why the most dangerous words in medicine aren’t always, “It’s all in your head.” Sometimes it’s the certainty behind them. History reminds us that today’s unexplained illness may become tomorrow’s textbook chapter.

• Every generation overestimates what it knows.²¹
• Every generation underestimates what remains to be discovered.

As Voltaire (writer and philosopher) observed, *”Doubt is not a pleasant condition, but certainty is absurd.”*²². Perhaps the best physicians aren’t the ones who always have the answers. They’re the ones willing to say, “I believe you.” I don’t know.” “Let’s keep looking.”

Notes & Sources

¹ Osler W. Aequanimitas, with Other Addresses to Medical Students, Nurses and Practitioners of Medicine. Philadelphia: P. Blakiston’s Son & Co.; 1904.
² Gawande A. Complications: A Surgeon’s Notes on an Imperfect Science. New York: Metropolitan Books; 2002.
³ Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. The Lancet. 1984;323(8390):1311-1315.
⁴ Devinsky O. Epilepsy throughout history. Epilepsy & Behavior. 2003;4(6):680-689.
⁵ Zondervan KT, Becker CM, Missmer SA. Endometriosis. New England Journal of Medicine. 2020;382:1244-1256.
⁶ Marshall BJ. Nobel Lecture: Helicobacter pylori and peptic ulcer disease. Nobel Foundation; 2005.
⁷ Compston A, Coles A. Multiple sclerosis. The Lancet. 2008;372:1502-1517.
⁸ Devinsky O. Epilepsy throughout history. Epilepsy & Behavior. 2003;4(6):680-689.
⁹ National Institute of Neurological Disorders and Stroke. Parkinson’s Disease Information Page.
¹⁰ Institute of Medicine. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: National Academies Press; 2015.
¹¹ Nobel Foundation. Nobel Prize in Physiology or Medicine 2005.
¹² Centers for Disease Control and Prevention. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS).
¹³ Thomas L. The Medusa and the Snail. New York: Viking Press; 1979.
¹⁴ Davis HE, McCorkell L, Vogel JM, Topol EJ. Long COVID: major findings, mechanisms and recommendations. Nature Reviews Microbiology. 2023.
¹⁵ Slavich GM, Irwin MR. From stress to inflammation and major depressive disorder. Psychological Bulletin. 2014;140(3):774-815.
¹⁶ Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine. 1998;14(4):245-258.
¹⁷ McEwen BS. Protective and damaging effects of stress mediators. New England Journal of Medicine. 1998;338:171-179.
¹⁸ Dantzer R, O’Connor JC, Freund GG, Johnson RW, Kelley KW. From inflammation to sickness and depression. Nature Reviews Neuroscience. 2008;9:46-56.
¹⁹ Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed. New York: Henry Holt; 2004.
²⁰ Mukherjee S. The Song of the Cell. New York: Scribner; 2022.
²¹ Kuhn TS. The Structure of Scientific Revolutions. 4th ed. Chicago: University of Chicago Press; 2012.
²² Voltaire. The Philosophical Dictionary. 1764.

Additional Sources

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: APA Publishing; 2022.

Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127(23):2336-2342.

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“The good physician treats the disease; the great physician treats the patient who has the disease.” William Osler (physician)¹

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It may be the most remarkable object in your home. Not your phone. Not your computer. Not even your car.

A pill.

Small enough to disappear beneath your fingernail, yet powerful enough to lower blood pressure, stop a seizure, replace a missing hormone, prevent a transplanted organ from rejecting a transplanted kidney, cure an infection that would once have been fatal, or quiet the emotional earthquake of bipolar disorder. Every morning, billions of pills are swallowed around the world with remarkably little hesitation. We rarely stop to wonder who first discovered them, how they were tested, who manufactured them, or why they work. We simply trust that somewhere, someone has already asked those questions for us.

That trust is extraordinary.

• Americans fill more than 6 billion prescriptions each year.²
• Nearly two-thirds of American adults take at least one prescription medication annually.³
• Adults over age 65 take an average of four to five prescription medications every day.⁴

For something so commonplace, pills occupy a surprisingly complicated place in our culture. We celebrate antibiotics without giving them much thought, yet argue endlessly about antidepressants. We admire someone who faithfully takes insulin while quietly wondering whether a person taking lithium or Adderall has somehow become “dependent.” Medications for the heart, lungs, kidneys, or thyroid rarely become moral questions, but medications that affect the brain often do. Somewhere between the pharmacy and the medicine cabinet, chemistry becomes philosophy.

As the physician and essayist Lewis Thomas observed, “The greatest of all the accomplishments of twentieth-century science has been the discovery of human ignorance.”⁵ Every generation has celebrated medicines that seemed almost miraculous. Penicillin transformed infections that had killed people for centuries. Insulin changed type 1 diabetes from a fatal disease into a chronic one. Vaccines nearly eliminated illnesses that once filled children’s hospitals. More recently, GLP-1 medications have changed the treatment of obesity, while ketamine has challenged decades of assumptions about severe depression.⁶ Now we are actually investigating psychedelics. The history of medicine is full of discoveries that initially seemed almost magical.

What interests me even more, however, is not the chemistry inside the pill but the meaning we attach to it.

As a psychiatrist, I spend surprisingly little time convincing patients that medications can work. Most people already believe that. The conversations are almost always about something else. Patients ask whether a medication will change their personality, whether they will need it forever, whether taking it means they have somehow failed, or whether they will stop feeling like themselves. Those are not pharmacological questions. They are questions about identity, responsibility, and what it means to remain ourselves while accepting help.

Those questions did not begin with Prozac or Adderall. They have accompanied medicine for thousands of years. To understand why we continue asking them, we have to begin long before pharmaceutical companies, clinical trials, or even pharmacies themselves. We have to return to ancient Egypt, where physicians wrapped bitter herbs in honey and dates, hoping patients would swallow remedies that sometimes worked, often didn’t, and almost always required faith.

The history of the pill turns out to be much more than the history of medicine. It is also the history of what human beings have always hoped medicine might become.

Honey, Dates, and Snake Oil

“The desire to take medicine is perhaps the greatest feature which distinguishes man from the other animals.” William Osler¹⁰

Long before there were pharmacists, there were healers. Long before there were prescriptions, there were recipes. And long before medicine became a science, it was an experiment repeated thousands of times by people who were simply trying to ease suffering with whatever nature happened to provide.

One of the earliest surviving medical texts is the Egyptian Ebers Papyrus, written around 1550 BCE. It contains more than seven hundred remedies for ailments ranging from intestinal parasites to skin diseases, breathing problems, fractures, and mental disturbances.¹¹ Egyptian physicians were remarkably sophisticated observers, but they faced the same problem every parent faces today.

How do you convince someone to swallow something that tastes terrible?

Their solution was wonderfully practical. Bitter herbs, powdered minerals, and other medicinal ingredients were mixed with honey or mashed dates, then rolled into small balls that could be swallowed whole. They were not pills in the modern sense, but they were close enough that the basic idea has survived for nearly four thousand years.

• The Ebers Papyrus contains more than 700 medicinal formulas.¹²
• Honey has been used medicinally for at least 4,000 years.¹³
• Ancient Egyptian physicians prescribed everything from willow bark to crocodile dung.

Fortunately, only one of those eventually became aspirin.

The Greeks inherited much of Egyptian medicine, and the Romans eagerly borrowed from the Greeks. Medieval apothecaries refined the art of preparing medicines, coating pills with sugar because patients then, just like patients now, preferred not to gag. Physicians gradually became better at recognizing which remedies appeared to help, but they usually had no idea why they worked. Medicine advanced by observation far more often than by understanding. Sometimes that approach led to genuine breakthroughs. Sometimes it led to centuries of bloodletting, mercury, arsenic, and treatments that probably harmed more people than they healed.

• Bloodletting remained a standard medical treatment for nearly two thousand years.
• Mercury was prescribed for everything from constipation to syphilis.
• Cocaine, heroin, cannabis, alcohol, and opium have all been sold legally as medicines.

As Lewis Thomas wrote, “Our triumphs are not in our understanding but in our noticing.”¹⁴ That sentence captures much of medical history. Long before anyone understood bacteria, neurotransmitters, or DNA, observant physicians occasionally noticed that certain treatments consistently seemed to help. They lacked explanations, but they had evidence, even if they didn’t yet know how to interpret it.

Unfortunately, uncertainty also creates opportunity.

By the nineteenth century, medicine had become one of the fastest-growing businesses in the world. If you owned a bottle, a printing press, and enough confidence, you could market yourself as a medical expert. Newspapers overflowed with advertisements promising relief from nervous exhaustion, melancholy, baldness, indigestion, alcoholism, “female weakness,” and almost every inconvenience associated with being alive. Many of those miracle cures contained generous amounts of alcohol, morphine, cocaine, or opium. Patients often reported dramatic improvement, which probably says as much about the ingredients as the advertising.

• Mrs. Winslow’s Soothing Syrup, marketed for teething infants, contained morphine.
• Bayer introduced heroin in 1898 as what was believed to be a safer alternative to morphine.
• Cocaine appeared in wines, toothache drops, tonics, and countless over-the-counter remedies before its dangers were fully understood.

Years ago, I became friends with Jim Hogshire, whose wonderfully eccentric collection of essays, Pills A-Go-Go, chronicles this era with equal parts fascination and disbelief. Reading those old advertisements today is like opening a pharmaceutical time capsule. The illustrations feel quaint, the language melodramatic, and the medical claims almost comically exaggerated. Then, after a few pages, something slightly uncomfortable happens.

You begin to recognize them. The fonts are different. The regulations are stricter. The television commercials are certainly better produced.

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But the promise remains remarkably familiar. Yesterday’s advertisements offered stronger nerves, renewed energy, happier marriages, calmer children, and a better night’s sleep. Today’s advertisements promise sharper concentration, better sex, lower cholesterol, weight loss, smoother skin, and freedom from diseases most of us had never heard of until the commercial interrupted our favorite television show.

As George Carlin observed, “The reason they call it the American Dream is because you have to be asleep to believe it.”¹⁵ He wasn’t talking about pharmaceuticals, but he understood something about advertising. We have always wanted to believe that somewhere, someone has discovered the medicine that will not merely make us healthier, but make life itself a little easier.

Medicine gradually became a science. Selling medicine never stopped being an art.

Mother’s Little Helper

“There is no health without mental health.” David Satcher (former U.S. Surgeon General)¹⁶

By the middle of the twentieth century, medicine had entered an age that would have seemed miraculous to almost every physician who had come before it. Antibiotics cured infections that had once killed young adults in the prime of life. Vaccines emptied children’s hospital wards. Insulin transformed type 1 diabetes from a fatal diagnosis into a chronic illness. Surgery became safer. Life expectancy climbed. For perhaps the first time in history, physicians could reasonably expect many of their patients to recover.

Success changes expectations.

Once medicine demonstrated that it could cure disease, people naturally began wondering what else it might improve. If a pill could eliminate pneumonia, why couldn’t another make us less anxious? If one could stop seizures, perhaps another could sharpen attention. If chemistry could restore health, perhaps it could also make ordinary life a little easier to live.

That wasn’t simply wishful thinking. It became one of the most successful advertising campaigns in history.

• Miltown became the first blockbuster tranquilizer.
• By the early 1970s, Valium was among the most prescribed medications in the world.
• Amphetamines were widely marketed for weight loss, energy, and what advertisements cheerfully described as “pep.”

Looking back at those advertisements today is equal parts amusing and unsettling. Smiling women in pearls happily vacuumed the house, then served dinner because their “nerves” had finally settled down. Husbands returned home to cheerful wives. Children behaved. The kitchen sparkled. Reading them now, it is difficult not to wonder whether the medication was treating anxiety or simply making impossible expectations feel a little more tolerable.

No one captured that contradiction better than Mick Jagger and Keith Richards in the Rolling Stones’ 1966 song Mother’s Little Helper. The song is often described as being about Valium, but it is really about something much larger. It asks what happens when ordinary exhaustion, loneliness, boredom, and disappointment begin to look like medical problems waiting for pharmaceutical solutions.

That question has never gone away.

As Carrie Fisher once observed, “If my life wasn’t funny, it would just be true, and that is unacceptable.”¹⁷ Humor often notices cultural shifts long before medicine does. Comedians, musicians, and novelists had already begun asking whether we were drifting from treating illness toward treating the ordinary frustrations of everyday life.

• Cigarettes were once advertised by physicians.
• Coca-Cola originally contained cocaine and 7-Up once contained lithium.
• Heroin, cocaine, amphetamines, barbiturates, and benzodiazepines have all, at one time or another, been celebrated as modern medical breakthroughs.

It is tempting to laugh at those advertisements because they seem so obviously misguided. The danger is believing we have become immune to making similar mistakes. History has a way of humbling every generation. We shake our heads at Victorian patent medicines while confidently embracing today’s newest miracle drug, forgetting that our grandchildren may someday look back at our own advertisements with exactly the same mixture of amusement and disbelief.

That does not mean medicine has failed. Quite the opposite. Many of those medications remain enormously valuable when used for the right patient, in the right circumstance, and for the right reason. Amphetamines remain among the most effective treatments for ADHD. Benzodiazepines can be lifesaving during severe panic attacks, alcohol withdrawal, or acute agitation. Opioids remain indispensable after major surgery and in hospice care. The problem has never been the medications themselves.

The problem is that medicine is often asked to answer questions that are not entirely medical. Where does illness end and ordinary human suffering begin?

The grieving widow who cannot stop crying may not have major depression. The overwhelmed college student may not have ADHD. The exhausted parent juggling two jobs and three children may not have an anxiety disorder. At the same time, genuine depression, ADHD, and anxiety disorders are every bit as real as diabetes or asthma, and dismissing them as ordinary stress can be just as harmful as overdiagnosing them.

The line separating illness from the normal struggles of being human has never been as sharp as we would like it to be. Every generation redraws that line a little differently, influenced by new discoveries, changing social expectations, and sometimes by very effective advertising. That uncertainty has become one of medicine’s greatest challenges. It has also become one of psychiatry’s.

Medicine Is Part Chemistry, Part Theater

“The art of medicine consists of amusing the patient while nature cures the disease.” Voltaire¹⁸

At first glance, Voltaire’s observation sounds like a cynical dismissal of medicine. In fairness to him, he wrote those words nearly a century before physicians understood that bacteria caused infections and almost two centuries before antibiotics transformed modern medicine. Most of the treatments available in his lifetime were ineffective, and some were actively harmful. A wise physician often accomplished more by listening carefully, offering reassurance, and avoiding dangerous interventions than by prescribing the fashionable treatment of the day.

Oddly enough, modern medicine has brought us back to appreciating part of what Voltaire meant. Not because medicine doesn’t work. Because patients do.

One of the most fascinating discoveries in medicine is that expectation itself can influence biology. Researchers have repeatedly shown that patients who believe they are receiving an effective pain medication often experience genuine pain relief even when they have received an inert pill. Brain imaging demonstrates measurable changes in the same pain-processing regions activated by opioid medications. Patients with Parkinson disease may release dopamine simply because they believe they are receiving treatment. Even sham surgical procedures, performed as part of carefully controlled clinical trials, have occasionally produced improvements surprisingly close to those seen after the actual operation.¹⁹

• Placebo responses have been demonstrated in chronic pain, depression, anxiety, Parkinson disease, migraine, and irritable bowel syndrome.
• Brain imaging shows that expectation activates many of the same neural pathways influenced by active medications.
• Patients who expect treatment to help are, on average, more likely to improve.

The opposite is equally true. Patients warned that a harmless pill commonly causes headaches, nausea, or dizziness are substantially more likely to experience those symptoms, even when the pill contains no active medication. Physicians have a name for this phenomenon. It is called the nocebo effect. Expectations can relieve suffering, but they can also create it.

As Lewis Thomas wrote, “We are, perhaps, much more than we know.”²⁰ The brain is not simply observing treatment from a distance. It is participating in it, interpreting it, and, in some cases, amplifying it.

That realization changes the way we think about many controversial treatments. Homeopathy, for example, remains scientifically implausible because most preparations contain little or none of the original substance. Yet many patients sincerely report feeling better after taking it. Critics often interpret those reports as evidence that patients are foolish or easily deceived. I think that misses the more interesting question.

What else happened? Did someone spend an hour listening carefully instead of fifteen rushed minutes? Did the patient finally feel heard? Did hope replace despair? Did sleeping improve because anxiety diminished? Did the act of believing that recovery was possible encourage someone to exercise, reconnect with friends, or pay closer attention to nutrition?

None of those experiences violates biology. They are biology.

• Larger pills are generally perceived as stronger than smaller ones.
• Patients consistently rate injections as more powerful than pills, even when the medication is identical.
• The color of a pill can influence expectations, with blue tablets often perceived as calming and red tablets as stimulating.

Comedian Tim Minchin likes to remind audiences, “You know what they call alternative medicine that’s been proved to work? Medicine.” The joke lands because it contains an important truth. Treatments that repeatedly demonstrate effectiveness eventually become part of ordinary medicine. Yet modern medicine has taught us something equally important. The molecule inside the pill is only one part of the treatment. Trust matters. Empathy matters. Listening matters. Explaining matters. A physician’s confidence, a patient’s expectations, and the relationship between them can all influence the final outcome.

That realization has changed the way I practice psychiatry. Writing the prescription is often the easiest part of the visit. Helping patients understand why a medication is being prescribed, what it can realistically accomplish, what it cannot accomplish, and why I believe it is worth trying often takes considerably longer.

Perhaps that is because prescribing a medication is only partly about chemistry. The rest is about earning trust.

One Pill Is Almost Never Enough

“For every complex problem there is an answer that is clear, simple, and wrong.” H. L. Mencken (journalist)²¹

One of the questions I hear most often is wonderfully straightforward. “Can’t you just give me one medication?”

Patients usually ask it after I’ve explained that I’d like to add a second medication rather than increase the dose of the first. They assume I’m changing course because the original prescription somehow failed.

In fact, the opposite is often true.

One of the quiet revolutions in modern medicine has been the realization that complex illnesses rarely respond to simple solutions. Physicians once dreamed of finding a single “magic bullet” for every disease. Increasingly, we’ve learned that biology doesn’t organize itself that neatly. The heart, the immune system, the endocrine system, and especially the brain all depend on countless interacting pathways. Changing one of them may solve part of the problem while leaving several others untouched.

• More than half of patients treated for hypertension eventually require two or more medications.
• Modern HIV treatment relies on combinations of antiviral medications.
• Many cancers are now treated with carefully designed combinations of surgery, radiation, chemotherapy, immunotherapy, and targeted medications.

Psychiatry follows exactly the same logic.

Patients with bipolar disorder often ask why they need lithium and lamotrigine, or lithium and an antipsychotic, instead of one medication that simply treats “bipolar disorder.” The answer is that bipolar disorder is not one biological problem. Mania and depression involve overlapping but distinct neural circuits. Sleep, circadian rhythms, inflammation, genetics, stress hormones, and neurotransmitters all interact continuously. A medication that does an excellent job preventing mania may do very little for bipolar depression. Another may improve depression but provide little protection against mania. Combining them is not an admission of defeat. It is an acknowledgment of reality.

That way of thinking has quietly spread throughout medicine. HIV became a manageable chronic illness only after physicians stopped searching for a single miracle drug and began attacking the virus from several different directions at once. Cancer specialists routinely combine treatments because tumors adapt when confronted with only one. Infectious disease physicians prescribe multiple antibiotics for tuberculosis for exactly the same reason.

Medicine has become less interested in finding one perfect answer. It has become much better at finding combinations that work.

• The word “polypharmacy” simply means using multiple medications, although the term is often used when combinations become excessive or unnecessary.
• Evidence-based combination therapy is standard practice throughout cardiology, oncology, infectious disease, rheumatology, and psychiatry.
• The goal is never to prescribe more medications. The goal is to prescribe enough medications to solve the problem while creating the fewest new ones.

Of course, every additional medication increases the possibility of side effects, and that is where psychiatry often becomes frustrating for both physicians and patients. Some of our most effective antipsychotic medications dramatically improve psychosis while simultaneously increasing appetite, reducing insulin sensitivity, and altering metabolism. A patient may finally think clearly after years of hallucinations, only to gain sixty pounds over the following year.

Patients naturally ask why pharmaceutical companies cannot simply eliminate those side effects. The answer is that the receptors involved in thought, appetite, movement, sleep, and metabolism are not isolated from one another. Evolution recycled the same biological machinery over and over again. A receptor helping regulate mood in one part of the brain may also participate in hunger somewhere else. Alter one system and several others often respond.

That is one reason I find recent developments so interesting. Years ago, psychiatrists often prescribed metformin to reduce antipsychotic-associated weight gain. More recently, GLP-1 receptor agonists have shown even greater promise. We have reached the curious point where one medication is sometimes prescribed to reduce the side effects of another.

At first glance, that sounds absurd. In reality, it is exactly how medicine has always progressed. Every generation discovers that the body is more complicated than it first appeared, and every generation responds by developing more precise ways of working with that complexity. The goal has never been to prescribe more pills.

The goal has always been to help patients live better lives with as little medication as possible, but as much as necessary. That distinction becomes especially important when the medication affects the organ we associate with our very identity.

Will This Change Who I Am?

“The physician’s essential task is to recognize the patient’s humanity.” Oliver Sacks (neurologist)²²

If there is one question that separates psychiatry from nearly every other medical specialty, it is not whether the medication will work. It is whether the medication will change the person taking it.

Patients rarely ask a cardiologist whether a blood pressure medication will alter their personality. They don’t usually ask an endocrinologist whether insulin will make them feel like someone else. They may worry about side effects, cost, or inconvenience, but they seldom wonder whether treating diabetes or hypertension somehow changes who they are.

Psychiatry is different.

Not because psychiatric medications are uniquely powerful, but because they affect the organ we associate with memory, personality, humor, ambition, love, creativity, and consciousness itself. When patients agree to begin an antidepressant, stimulant, mood stabilizer, or antipsychotic, they are not simply trusting me with an illness. They are trusting me with what they experience as their very self.

• Nearly one in five American adults experiences a mental illness each year.
• Fear of “personality change” remains one of the leading reasons patients hesitate to begin psychiatric medication.
• Psychiatric medications remain among the most stigmatized treatments in medicine.

Those fears did not appear out of nowhere. For nearly a century our novels, movies, and television shows have warned us about medications that erase individuality. In Aldous Huxley’s Brave New World, people take soma not because they are sick, but because it keeps them comfortable, compliant, and unwilling to question society. Ken Kesey’s One Flew Over the Cuckoo’s Nest portrayed psychiatric hospitals as places where medication was used as much to control as to heal. Decades of films have reinforced the same image, depicting psychiatric medications as chemical restraints that flatten emotion and extinguish creativity.

It is hardly surprising that patients walk into my office wondering whether medication will turn them into someone they no longer recognize. What has always struck me is the irony. Untreated mental illness changes personality far more dramatically than most psychiatric medications ever do.

Depression steals curiosity long before it steals happiness. Friends notice that someone laughs less, withdraws from conversations, loses interest in hobbies, and stops returning phone calls. Anxiety gradually shrinks the boundaries of life until vacations, restaurants, airplanes, and even grocery stores begin disappearing from someone’s world. Obsessive-compulsive disorder replaces freedom with ritual. Bipolar disorder can transform a thoughtful, cautious person into someone who spends recklessly, sleeps two hours a night, destroys relationships, or believes they have become invincible. Schizophrenia can make reality itself unreliable.

By the time many patients arrive in my office, the illness has already been changing them for months, sometimes years. Treatment is an attempt to interrupt that process.

As Oliver Sacks spent his career reminding us, physicians treat diseases, but they care for people. I have never thought of my job as creating a new personality. If treatment is working well, patients rarely become different people. More often they begin sounding like the person their spouse remembers, the child their parents recognize, or the version of themselves they thought had disappeared. The woman whose depression had stolen her laughter laughs again. The teenager with ADHD finishes a conversation without drifting away halfway through a sentence. The man with panic disorder attends his daughter’s wedding instead of staying home because the thought of traveling had become unbearable.

Those moments rarely feel like transformation. They feel like restoration.

• Effective treatment for ADHD reduces accidental injuries, substance misuse, and motor vehicle accidents.
• Effective treatment for bipolar disorder lowers relapse rates, hospitalization, and suicide.
• Successfully treating depression often improves physical health as well as emotional well-being.

That perspective also explains why I answer another common question a little differently than patients expect.

“How long will I have to take this?”

People are often surprised when I respond with a question of my own.

“How long do you plan on having ADHD?”

Or bipolar disorder. Or schizophrenia.

It is not meant to be clever. It is meant to shift the conversation.

We do not ask how long someone should continue taking insulin for type 1 diabetes or when they can finally stop wearing eyeglasses. We understand that those treatments help people function in the presence of an ongoing condition. Psychiatric medications are no different. Some people take them for months. Others take them for decades. The decision is guided by the illness itself, not by an arbitrary calendar.

That does not mean everyone should remain on medication forever. Some conditions resolve completely. Others improve enough that medication can be reduced or discontinued. One of the most satisfying conversations I have with patients is deciding together that they no longer need something I once prescribed. Good psychiatry should always involve asking whether each medication is still necessary, not simply continuing it because it has become part of the routine.

As Viktor Frankl wrote, “Between stimulus and response there is a space. In that space is our power to choose our response.”²³ Severe mental illness narrows that space. Depression convinces people there is no future. Panic disorder persuades them there is no escape. Mania eliminates caution. Psychosis distorts reality itself. At its best, treatment widens that space again.

That is why I have never liked the expression “happy pills.” The goal of psychiatric medication is not to manufacture happiness or create artificial contentment. It is to reduce enough suffering that patients can begin making meaningful choices again, rebuilding relationships, pursuing work they enjoy, raising children, finding purpose, and reclaiming lives that illness had gradually taken away.

Perhaps that is the most important distinction in all of psychiatry. The best medications do not change who we are. They help us become ourselves again.

The Search Continues

“The important thing in science is not so much to obtain new facts as to discover new ways of thinking about them.” Sir William Lawrence Bragg (physicist and Nobel laureate)²⁴

If medicine has taught us anything over the past four thousand years, it is that certainty has an unusually short shelf life.

Egyptian physicians believed they understood disease. So did the Greeks. Medieval physicians confidently prescribed bloodletting. Nineteenth-century doctors embraced mercury, arsenic, cocaine, heroin, and countless patent medicines that promised miraculous results. Every generation has looked back at the one before it with a mixture of amusement and disbelief, convinced that modern science had finally separated fact from fantasy.

Then the next generation arrived.

That perspective has changed the way I think about psychiatry. Early in my career I thought of medications largely in terms of neurotransmitters. Increase serotonin. Decrease dopamine. Strengthen norepinephrine. The model was useful, and it remains useful today, but it also turns out to be incomplete. As our understanding of the brain has expanded, those familiar neurotransmitters have become part of a much larger story involving inflammation, genetics, circadian rhythms, neuroplasticity, immune signaling, the microbiome, hormones, and dozens of biological systems that interact in ways we are only beginning to understand.

• Most psychiatric medications were discovered before scientists understood precisely how they worked.
• There is still no laboratory test that diagnoses depression, bipolar disorder, schizophrenia, or ADHD. Certainly no imaging.
• Every one of those diagnoses almost certainly represents many different biological illnesses rather than a single disease.

That is one reason lithium has become even more interesting with age. When John Cade first introduced it in 1949, physicians knew it stabilized mood because they could see the results. Only decades later did researchers begin discovering that lithium appears to protect neurons, influence intracellular signaling, increase neurotrophic factors, and promote neuroplasticity. The medication had been quietly doing far more than anyone realized.

Ketamine followed a remarkably similar path. Developed as an anesthetic, it was never intended to become an antidepressant. Yet some patients with severe depression improved within hours rather than weeks, forcing psychiatrists to rethink assumptions that had gone largely unchallenged for decades. Today the leading theories suggest that ketamine may rapidly strengthen or restore synaptic connections damaged by chronic stress and depression rather than simply altering neurotransmitter levels.²⁵

• Lithium remains the only psychiatric medication consistently shown to reduce suicide risk in bipolar disorder.
• Ketamine can reduce depressive symptoms, including suicidal ideation, within hours in some patients.
• Exercise, sleep, psychotherapy, learning, and meaningful relationships all promote neuroplasticity.

That last observation may ultimately prove more important than either medication.

Patients often ask whether medication or psychotherapy works better, as though they are competing treatments. The brain makes no such distinction. A meaningful conversation changes the brain. So does learning a new language, recovering from grief, falling in love, exercising regularly, sleeping well, raising children, reading a book, or living through a pandemic. Every experience leaves fingerprints on the nervous system. Medication is not an alternative to those experiences. It is sometimes what makes them possible.

As neuroscientist Eric Kandel famously demonstrated, learning itself changes the structure of the brain.²⁶ Once you accept that idea, one of psychiatry’s oldest debates begins to dissolve. Medication versus therapy becomes medication and therapy. Biology and psychology stop competing because they were never separate in the first place. Every thought is biological. Every biological change influences thought.

Looking back over the history of medicine, I no longer think it is the story of humanity searching for the perfect pill. It is the story of humanity gradually learning how difficult healing really is. The more carefully physicians have studied the body, the less mysterious many diseases have become, but the more awe-inspiring the human organism has become in return. Every answer uncovers another layer of complexity. Every discovery opens an entirely new field of questions.

That is not discouraging. It is the reason medicine continues to move forward.

Perhaps there never will be a medication that cures every form of depression, prevents every psychotic illness, or eliminates bipolar disorder forever. Perhaps the future lies instead in understanding which combinations of medication, psychotherapy, exercise, nutrition, sleep, education, relationships, and purpose allow each individual brain to function at its best. That future is less glamorous than the search for a miracle drug, but it is probably far more realistic.

When I began writing this article, I thought it was going to be about pills. Somewhere along the way I realized it is really about trust.

Every time we swallow a medication we place enormous faith in generations of physicians, scientists, pharmacists, patients, and researchers who devoted their lives to understanding a tiny piece of human biology. They made remarkable discoveries, made spectacular mistakes, corrected many of them, and left the next generation with better questions than they inherited themselves.

That may be the real history of medicine. Not a story about magic. A story about curiosity. About humility. And about an enduring belief that tomorrow we may understand just a little more than we do today. For something small enough to disappear beneath a fingernail, that is a remarkable legacy.

Notes & Sources

1. William Osler. Aequanimitas, with Other Addresses to Medical Students, Nurses and Practitioners of Medicine. Philadelphia: P. Blakiston’s Son & Co., 1904.

2. IQVIA Institute. The Use of Medicines in the U.S. Annual reports.

3. U.S. Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. Prescription medication use among U.S. adults.

4. Agency for Healthcare Research and Quality (AHRQ). Medication use among older adults.

5. Lewis Thomas. The Medusa and the Snail. Viking Press, 1979; and The Lives of a Cell. Viking Press, 1974.

6. John Cade. “Lithium Salts in the Treatment of Psychotic Excitement.” Medical Journal of Australia. 1949. See also contemporary reviews on lithium, neuroprotection, neuroplasticity, and suicide prevention.

7. The Ebers Papyrus, c. 1550 BCE.

8. Edward Kremers and Glenn Sonnedecker. Kremers and Urdang’s History of Pharmacy.

9. Liddell and Scott. A Greek-English Lexicon. Entry: pharmakon.

10. William Osler. “The desire to take medicine is perhaps the greatest feature which distinguishes man from the other animals.” Commonly cited from Aequanimitas and related writings.

11. Jim Hogshire. Pills A-Go-Go. Essays on pharmaceutical advertising, drug culture, and the history of medications.

12. David Satcher. U.S. Surgeon General’s reports on mental health.

13. Mick Jagger and Keith Richards. “Mother’s Little Helper.” Aftermath. The Rolling Stones, 1966.

14. Fabrizio Benedetti. Placebo Effects (Oxford University Press) and related research on placebo and nocebo mechanisms.

15. Tim Minchin. Public lectures and performances discussing evidence-based medicine and alternative medicine.

16. Oliver Sacks. The Man Who Mistook His Wife for a Hat and An Anthropologist on Mars.

17. Aldous Huxley. Brave New World. London: Chatto & Windus, 1932.

18. Ken Kesey. One Flew Over the Cuckoo’s Nest. Viking Press, 1962.

19. Sir William Lawrence Bragg. Scientific writings and lectures.

20. Eric Kandel. Principles of Neural Science (with colleagues), In Search of Memory, and related work on learning, memory, and neuroplasticity. See also Carlos Zarate Jr. and colleagues on ketamine in treatment-resistant depression, and recent reviews of GLP-1 receptor agonists for antipsychotic-associated weight gain.

Further Reading

• David Healy. The Antidepressant Era.

• Stephen M. Stahl. Stahl’s Essential Psychopharmacology.

• Robert Whitaker. Anatomy of an Epidemic.

• Jerome Groopman. How Doctors Think.

• Atul Gawande. Complications and Better.

• Siddhartha Mukherjee. The Emperor of All Maladies and The Gene.

• Lewis Thomas. Late Night Thoughts on Listening to Mahler’s Ninth Symphony.

• Oliver Sacks. Awakenings.

• American Psychiatric Association Practice Guidelines.

• Canadian Network for Mood and Anxiety Treatments (CANMAT) Guidelines.

• U.S. Food and Drug Administration historical archives on patent medicines and the Pure Food and Drug Act of 1906.

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For most of human history, families gathered around tables not because they agreed about everything, but because they belonged to one another. Anthropologists have long argued that communal meals, weddings, funerals, religious holidays, and seasonal festivals weren’t simply traditions. They were survival technologies that reinforced cooperation in small groups. Long before there were governments, there were families, and long before there were constitutions, there were shared stories reminding everyone that no one faced the world alone.

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Today, the family dinner table often feels like a diplomatic summit.

Every November, newspapers publish some version of the same article: How to Talk to Your MAGA Uncle. How to Deal with Your Liberal Cousin. How to Survive Thanksgiving. The joke works because everyone understands it. Somehow, one of humanity’s oldest rituals of belonging has become something to navigate with talking points, contingency plans, and emotional armor.

That should concern us. Not because democracy requires agreement. It never has. Jefferson and Hamilton disagreed relentlessly. Lincoln deliberately filled his cabinet with political rivals. Democracies don’t depend on consensus. They depend on the willingness to remain a community despite profound disagreement. What’s changed is that disagreement increasingly feels like betrayal.

I’ve heard versions of the same heartbreaking story from patients, friends, colleagues, and neighbors. Parents convinced their children have been brainwashed. Adult children convinced their parents have disappeared into cable news. Brothers who no longer speak. Sisters who quietly celebrate holidays separately. Grandchildren who avoid grandparents because no one can promise the conversation will remain civil.

The details change. The heartbreak doesn’t. Evolution didn’t prepare us for democracy. It prepared us for survival.

For roughly 300,000 years, belonging to the tribe wasn’t a luxury. It was the difference between life and death. A person rejected by the group was unlikely to survive for long. Natural selection therefore favored brains exquisitely tuned to loyalty, belonging, cooperation, and shared identity. Evolution didn’t reward our ancestors for winning debates. It rewarded them for remaining part of the group.

That ancient brain still lives inside us. Our tribes simply have new names. Political parties. Religions. Cable news networks. Podcasts. Social media feeds. The irony is difficult to ignore. The same psychological machinery that allowed human beings to cooperate well enough to survive an evolutionary bottleneck, build civilizations, and eventually walk on the Moon can also persuade us to see our own relatives as strangers.

As Yuval Noah Harari (historian) writes, “Humans think in stories rather than facts, numbers, or equations, and the simpler the story, the better.” Democracy therefore depends upon something evolution rarely demanded of us: listening respectfully to people outside our tribe.

Heather Cox Richardson (historian) has argued that democracy ultimately depends upon citizens maintaining a shared civic reality, while Timothy Snyder (historian) warns that authoritarianism begins not by changing laws but by changing what people believe is true. More than thirty years ago, Carl Sagan (astronomer and science communicator) recognized the same danger from a scientific perspective, writing, “If we’ve been bamboozled long enough, we tend to reject any evidence of the bamboozle.”

Notice what Sagan didn’t write. He didn’t say they. He said we. That may be the most important word in the sentence.

Science educator Dave Farina reminds his audience that the strength of science isn’t certainty but the willingness to abandon yesterday’s conclusions when tomorrow’s evidence demands it. Meanwhile, Jennifer Welch (podcaster) jokes that Americans increasingly treat political opinions like blood types, while George Carlin observed that everyone laughs at the stupidity of “other people,” never imagining they might belong to the same group.

Psychologists have a name for that tendency. The bias blind spot. We are remarkably good at recognizing irrationality in everyone except ourselves.

• Americans reporting politics has strained family relationships: about 40%

• Americans avoiding political discussions with certain relatives: more than one-third

• Approximate years modern humans have survived through cooperation: 300,000

• Number of “How to Survive Thanksgiving” articles published every November: too many to count

Perhaps democracy’s greatest achievement has never been convincing us to agree. Perhaps it has been asking our Stone Age brains to do something they were never designed to do. Treat people outside the tribe as though they belong to it. Everything else in this article begins there.

Why Propaganda Works on Good People

If propaganda only fooled unintelligent people, it would have disappeared long ago. Instead, it has shaped virtually every civilization in history. That’s because propaganda doesn’t exploit stupidity. It exploits a brain that evolved for survival rather than objective truth. Our ancestors survived because they rapidly distinguished friend from foe, trusted their own group, and responded quickly to danger. Those instincts saved lives for hundreds of thousands of years. They also left us vulnerable to anyone skilled at manipulating them.

Propaganda rarely begins by asking people to become cruel. It begins by asking them to become afraid. Afraid that someone is coming for their children. Their jobs. Their religion. Their freedoms. Their country.

Once fear takes hold, the brain changes its priorities. The question quietly shifts from “Is this true?” to “Am I safe?” Evolution designed that response because hesitation in the face of a predator could be fatal. But the same survival system that once helped our ancestors escape lions can make modern humans surprisingly susceptible to misinformation, tribalism, and authoritarianism.

As Hannah Arendt (political philosopher) observed after covering Adolf Eichmann’s trial, evil is often frighteningly ordinary. Her phrase, “the banality of evil,” wasn’t meant to excuse atrocities. It was a warning that history’s greatest horrors are frequently committed by people who believe they are simply doing their duty.

Neuroscientist Robert Sapolsky has spent decades demonstrating that chronic stress changes the way we think. We become more reactive, less flexible, and more likely to divide the world into allies and enemies. That’s adaptive if a lion is chasing you. It’s a terrible way to run a democracy. Perhaps the greatest strength of propaganda isn’t that it changes minds. It’s that it narrows the circle of trust.

Once you’ve become convinced that only one television network, one political leader, one podcast, one church, or one website tells the truth, you’ve built a wall around your own thinking. Contrary evidence no longer arrives as information. It arrives as proof that everyone else is lying.

That’s why Timothy Snyder (historian) argues that one of the first goals of authoritarian movements is to undermine trust in independent institutions. Courts. Universities. Journalists. Scientists. Elections. Once citizens believe that no one outside the movement can be trusted, the movement itself becomes the only remaining source of reality.

Notice how different this is from simply lying. The most successful propagandists don’t merely convince people what to think. They convince them whom to trust. Everything else follows naturally. It’s believing it couldn’t happen to us.

• Germans who belonged to the Nazi Party by 1945: approximately 8.5 million

• Participants in Stanley Milgram’s (social psychologist) obedience experiments who administered what they believed were dangerous electric shocks: 65%

• Days during which approximately 800,000 people were murdered in the Rwandan genocide: 100

• Americans reporting little or no trust in the mass media: about two-thirds

Propaganda doesn’t defeat democracy by making citizens hate one another. It defeats democracy by convincing them they no longer inhabit the same reality. Once that happens, disagreement is no longer a debate. It becomes a battle between tribes.

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The Kind of Mind Democracy Requires

If evolution prepared us to survive in tribes, why do some people seem more comfortable questioning the tribe than others? Psychologists have been asking that question for decades. The answer isn’t intelligence. Highly intelligent people can become zealots just as easily as anyone else. The more interesting difference may be how comfortable people are living with uncertainty.

Children naturally think concretely. Rules are fixed. Good people are good. Bad people are bad. As the brain matures, particularly the prefrontal cortex through our twenties, most of us become increasingly capable of abstract thought. We begin to appreciate irony, ambiguity, competing values, and the possibility that two intelligent people can disagree without either being evil. Growing up, in many ways, means becoming comfortable with complexity. Not everyone reaches the same destination.

One of the most consistent findings in personality psychology is a trait known as openness to experience. People who score higher tend to be more curious, more tolerant of ambiguity, and more willing to revise their beliefs when confronted with new evidence. Those who score lower often prefer predictability, tradition, and clear rules. Neither style is inherently better. Every civilization needs people who preserve traditions as well as people who challenge them.

The danger comes when certainty replaces curiosity. This is where politics often becomes misleading. For years, researchers have reported average psychological differences between liberals and conservatives. Liberals, on average, tend to score somewhat higher on openness to experience. Conservatives, on average, tend to place greater value on stability, order, and tradition. Some neuroimaging studies have even suggested modest average differences in brain regions involved in processing threat and conflict.

Those findings are fascinating. They’re also easy to misuse. The differences are averages across millions of people. They are not diagnoses. There is enormous overlap. No MRI scanner can tell you how someone votes, and reducing political beliefs to brain anatomy is every bit as simplistic as reducing personality to eye color.

Still, one observation keeps appearing throughout the literature: people who perceive the world as more dangerous generally place greater value on order and security, while those who perceive it as relatively safe are often more willing to embrace novelty and uncertainty.

The operative word is perceive. Our brains don’t respond to reality. They respond to the reality they believe they’re living in. That insight may help explain why two people can watch the same event, read the same statistics, and reach completely different conclusions. They’re not necessarily processing different facts. They’re processing different worlds.

As Jonathan Haidt (social psychologist) has argued, liberals and conservatives often begin with different moral intuitions. Liberals tend to emphasize care and fairness, while conservatives often place greater weight on loyalty, authority, and sanctity alongside those same values. Neither side owns morality. They simply begin the moral conversation in different places.

Unfortunately, modern politics rewards the opposite of complexity. Every problem has one villain. Every question has one answer. Every compromise is weakness. Every election is “the most important in history.” The human brain loves simple stories. Reality almost never provides them.

Perhaps that’s why Richard Feynman (physicist) remains one of my intellectual heroes. He wrote, “I can live with doubt and uncertainty... I think it’s much more interesting to live not knowing than to have answers which might be wrong.” That sentence could just as easily describe democracy.

Democracy doesn’t require us to agree. It requires us to tolerate uncertainty long enough to keep listening.

• Human personality traits in the “Big Five” model: 5

• Age at which the prefrontal cortex generally reaches full maturity: mid-20s

• Political issues that can honestly be reduced to simple good-versus-evil stories: almost none

• The most dangerous phrase in politics: “It’s that simple.”

Perhaps the brain democracy requires isn’t the smartest one. Perhaps it’s the one most willing to remain curious after certainty would have been easier.

We Inherit More Than Genes

If evolution gave us the brain, who teaches it what to believe? The answer is everyone. Parents. Teachers. Friends. Religious leaders. Schools. Books. Television. Algorithms. Every generation is born into a world already under construction, inheriting not only knowledge but also fears, loyalties, prejudices, traditions, and stories. Civilization isn’t rebuilt from scratch every twenty-five years. It’s handed from one generation to the next.

That’s one reason I’ve become fascinated by epigenetics. For much of the twentieth century, biology taught that genes were destiny. Today we know the picture is more complicated. Experiences can influence how genes are expressed without altering the DNA itself. Stress, nutrition, illness, and environmental exposures can leave biological marks that affect the way the body functions. The DNA is the library.

Epigenetics is the librarian. The most intriguing question is whether some of those experiences can echo across generations. Research involving Holocaust survivors, the Dutch Hunger Winter, and other populations exposed to profound trauma suggests they sometimes can, although scientists continue debating how much reflects inherited biology versus parenting, prenatal development, and family culture. Whatever the mechanism, the implication is profound.

History doesn’t end when the history book closes. It continues living inside families. That realization made me wonder whether we’ve been asking the wrong question. We spend enormous effort studying how trauma is passed from one generation to the next. Why don’t we spend equal effort studying how compassion is transmitted? If fear can echo across generations, can curiosity? If violence can become cultural, can kindness? Can secure attachment, good schools, stable democracies, and loving families shape not only one generation, but the next?

Those questions are still largely unanswered. Perhaps the most surprising clue comes not from genetics, but from archaeology. Roughly 12,000 years ago, long before cities, writing, or perhaps even agriculture, people gathered at a place we now call Göbekli Tepe. Nearly every archaeologist who studies the site reaches a similar conclusion: whatever happened there, it appears to have been ritual. That observation has always fascinated me because it suggests that before humans built governments, they built meaning.

Religion, in one form or another, seems to be nearly universal throughout human history. That shouldn’t surprise us. Evolution didn’t simply produce a species capable of reasoning. It produced a species capable of believing together. Shared stories allowed strangers to cooperate, trust one another, raise children together, bury their dead, and eventually build civilizations. The specific stories changed from culture to culture.

The need for stories did not. That also explains something I’ve wondered about for years. Even as someone who is Jewish, I’ve always been struck by how simple many of Jesus’ ethical teachings appear to be: love your neighbor, forgive others, care for the poor, treat people as you would want to be treated. Yet two thousand years later, countless scholars, denominations, and televangelists have constructed astonishingly complicated interpretations around those remarkably straightforward ideas.

Years ago, while living in Pittsburgh, some friends and I would watch Christian television for hours. We weren’t mocking it. We were genuinely fascinated. We’d look at each other wondering whether everyone on the screen had somehow read a different Bible than everyone else. The conversations often felt surreal.

It finally occurred to me that this isn’t really about Christianity. It’s about human beings. Ideas evolve just as cultures evolve. Every generation inherits a story, interprets it through its own fears, ambitions, politics, and historical moment, then hands a slightly different version to the next. Sometimes those changes move us closer to the original ideals.

Sometimes they carry us astonishingly far away.

• Approximate age of Homo sapiens: 300,000 years

• Estimated size of one ancient human population bottleneck: 1,000-2,000 breeding individuals

• Approximate age of Göbekli Tepe: 12,000 years

• Number of known civilizations without shared rituals or belief systems: 0

Perhaps that’s our greatest inheritance. Not our genes. Our stories. And every generation must decide which stories deserve to survive.

The Cure Is Curiosity

If evolution prepared our brains for survival rather than objective truth, are we trapped by our own biology? I don’t think so. One of evolution’s greatest gifts is that the human brain remains remarkably adaptable throughout life. Every conversation, every book, every friendship, every mistake, and every success changes us a little. The same brain that can be manipulated can also learn.

The obstacle isn’t intelligence. It’s certainty. Most of us begin with the comforting assumption that we’re decent, rational people. Once that identity forms, our minds become remarkably good at protecting it. We notice evidence that supports what we already believe, discount evidence that doesn’t, and judge our own tribe more generously than everyone else’s. Daniel Kahneman (psychologist and Nobel laureate) spent much of his career demonstrating that these shortcuts aren’t character flaws. They’re ordinary features of the human mind.

The remarkable thing isn’t that we’re biased. It’s that we’re capable of recognizing those biases. That may be the greatest achievement of science. Science isn’t a collection of facts. It’s a disciplined way of discovering where we’re wrong. As Richard Feynman (physicist) famously wrote, “The first principle is that you must not fool yourself—and you are the easiest person to fool.” Few sentences better capture the humility that both science and democracy require.

That realization has gradually changed the way I think about propaganda. Perhaps the opposite of propaganda isn’t more information. Perhaps it’s curiosity. Curious people ask questions before choosing sides. They seek out people who disagree with them. They tolerate uncertainty long enough for evidence to accumulate. They understand that changing one’s mind isn’t surrender. It’s often progress.

Psychologists repeatedly find that one personality trait, openness to experience, is associated with greater curiosity and cognitive flexibility. That doesn’t make someone wiser or morally superior. It simply makes continued learning more likely. The real enemy isn’t liberalism. It isn’t conservatism. It’s the belief that we’ve reached the end of learning.

As Bertrand Russell (philosopher) observed, “The trouble with the world is that the stupid are cocksure and the intelligent are full of doubt.” Like all good aphorisms, it’s an exaggeration. But it points toward an important truth: wisdom often sounds less certain because it has encountered more complexity.

Perhaps intellectual maturity has very little to do with IQ. Perhaps it’s the ability to hold an opinion firmly enough to act, yet loosely enough to revise it when reality demands.

• Estimated number of documented cognitive biases: more than 180

• Scientific theories that have survived forever without revision: 0

• Number of words that may be hardest for any human being to say: “I was wrong.”

• Number of times curiosity has threatened a dictatorship: every time someone asked for evidence

If this article has a single message, it’s this: Evolution gave us the brain that helped our ancestors survive. Civilization asks us to build something evolution never could. A mind capable of remaining curious even when certainty feels safer.

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The Brain Democracy Requires

By now you may have noticed something. This article hasn’t really been about liberals or conservatives. It hasn’t been about Fox News or MSNBC. It hasn’t been about Donald Trump, Joe Biden, or any particular election. They’re examples. The subject has always been us.

The human brain is one of the most extraordinary objects in the known universe. It composed Beethoven’s Ninth Symphony, developed antibiotics, split the atom, decoded DNA, landed on the Moon, and built civilizations. The very same brain also invented slavery, concentration camps, the Holocaust, the Rwandan genocide, Jim Crow, and nuclear weapons. None of those events happened because humans suddenly became a different species.

They happened because the same brain that is capable of extraordinary compassion is also capable of extraordinary certainty.

Whenever I hear someone confidently say, “I could never have supported something like that,” I wonder how they know. If you had been born in Germany in 1915, Mississippi in 1850, Rwanda in 1965, or Cambodia in 1975, would you have become the hero of the story? Or would you have believed what your parents believed, what your teachers taught, what your neighbors repeated, what your religious leaders preached, and what everyone around you accepted as common sense?

I’d like to believe I’d have resisted. So would almost everyone else. History suggests we should all be a little more humble.

As Yuval Noah Harari (historian) has written, humans dominate the planet not because we’re the strongest or fastest animals, but because we’re uniquely capable of cooperating around shared stories. Those stories gave us civilizations, religions, democracies, science, and human rights. They’ve also justified crusades, slavery, genocides, and dictatorships. The problem has never been that human beings tell stories.

The problem is forgetting they’re stories. Every child enters the world knowing almost nothing. Language, mathematics, religion, democracy, prejudice, compassion, and hatred all have to be learned. Every generation inherits a world already under construction. Some of what we inherit is magnificent. Some of it is poisonous. Then, almost without realizing it, we become the architects of what the next generation will inherit.

That may be the most important responsibility any civilization has. Not deciding what to believe. Deciding what to pass on. As Carl Sagan (astronomer and science communicator) wrote, “Science is more than a body of knowledge; it is a way of thinking.” I would argue that democracy is, too. Democracy isn’t simply majority rule or free elections. It’s a way of thinking that asks us to question our own assumptions, tolerate uncertainty, listen to opposing views, and occasionally admit we were wrong.

Those are remarkably unnatural acts. Evolution prepared us to survive in tribes. Democracy asks us to cooperate with strangers. Evolution rewarded loyalty. Democracy rewards curiosity. Evolution taught us to fear outsiders. Democracy asks us to expand the definition of “us.” Perhaps that’s why democracy has always been such a fragile experiment. It requires a kind of brain evolution never demanded. One capable of placing truth above tribe. Curiosity above certainty. Humility above ideology.

• Approximate years Homo sapiens have existed: 300,000

• Approximate years democracy has existed in recognizable form: 2,500

• Time evolution has had to prepare us for democracy: essentially none

• Generation responsible for deciding what happens next: ours

I’ve spent my career trying to understand the human mind. The older I get, the less interested I become in whether someone is liberal or conservative. I’m much more interested in something else. Can they ask a sincere question? Can they tolerate uncertainty? Can they change their mind when the evidence changes? Can they remain connected to someone who disagrees with them?

Because those aren’t simply the habits of good scientists. They’re the habits of good citizens. And they may be the very qualities that determine whether democracy survives the remarkable, imperfect, tribal brains that evolution gave us.

Notes and Sources

1. Arendt, H. (1963). Eichmann in Jerusalem: A Report on the Banality of Evil. Viking Press.
2. Feynman, R. P. (1985). Surely You’re Joking, Mr. Feynman! W. W. Norton.
3. Gallup. Long-term surveys on Americans’ trust in institutions and mass media.
4. Haidt, J. (2012). The Righteous Mind: Why Good People Are Divided by Politics and Religion. Pantheon Books.
5. Harari, Y. N. (2015). Sapiens: A Brief History of Humankind. Harper.
6. Harari, Y. N. (2018). 21 Lessons for the 21st Century. Spiegel & Grau.
7. Henrich, J. (2015). The Secret of Our Success: How Culture Is Driving Human Evolution, Domesticating Our Species, and Making Us Smarter. Princeton University Press.
8. Henrich, J. (2020). The WEIRDest People in the World. Farrar, Straus and Giroux.
9. Kahneman, D. (2011). Thinking, Fast and Slow. Farrar, Straus and Giroux.
10. Lumey, L. H., et al. Studies of the Dutch Hunger Winter and the long-term biological effects of prenatal famine exposure.
11. Milgram, S. (1974). Obedience to Authority: An Experimental View. Harper & Row.
12. Pew Research Center. Reports on political polarization, partisan identity, trust in institutions, and family relationships (2014-present).
13. Pronin, E., Lin, D. Y., & Ross, L. (2002). “The Bias Blind Spot: Perceptions of Bias in Self Versus Others.” Personality and Social Psychology Bulletin, 28(3), 369-381.
14. Richardson, H. C. (2023). Democracy Awakening: Notes on the State of America. Viking.
15. Sagan, C. (1995). The Demon-Haunted World: Science as a Candle in the Dark. Random House.
16. Sapolsky, R. M. (2017). Behave: The Biology of Humans at Our Best and Worst. Penguin Press.
17. Sapolsky, R. M. (2023). Determined: A Science of Life Without Free Will. Penguin Press.
18. Schmidt, K. (2006). Sie bauten die ersten Tempel (They Built the First Temples). C.H. Beck. Foundational work on Göbekli Tepe, supplemented by subsequent archaeological publications.
19. Snyder, T. (2017). On Tyranny: Twenty Lessons from the Twentieth Century. Tim Duggan Books.
20. Snyder, T. (2018). The Road to Unfreedom. Tim Duggan Books.
21. Tomasello, M. (2019). Becoming Human: A Theory of Ontogeny. Harvard University Press.
22. Waddington, C. H. (1942). “The Epigenotype.” Endeavour, 1, 18-20.
23. Yehuda, R., & Lehrner, A. (2018). “Intergenerational Transmission of Trauma Effects: Putative Role of Epigenetic Mechanisms.” World Psychiatry, 17(3), 243-257.
24. Zimbardo, P. (2007). The Lucifer Effect: Understanding How Good People Turn Evil. Random House.

Individuals Quoted

• Hannah Arendt — Political philosopher

• George Carlin — Comedian

• Dave Farina — Science educator (Professor Dave Explains)

• Richard Feynman — Physicist

• Jonathan Haidt — Social psychologist

• Yuval Noah Harari — Historian

• Daniel Kahneman — Psychologist and Nobel laureate

• Heather Cox Richardson — Historian

• Bertrand Russell — Philosopher

• Carl Sagan — Astronomer and science communicator

• Robert Sapolsky — Neuroscientist

• Timothy Snyder — Historian

• Jennifer Welch — Political commentator and co-host of I’ve Had It

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Mine began in 1997.

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During a psychopharmacology course, my professor wheeled a television into the classroom, dimmed the lights, and announced we were watching a documentary about Tourette syndrome. Like most of my classmates, I was certain I already knew what Tourette syndrome was. It was the disorder where people uncontrollably shouted obscenities, right?¹ Medical school would later teach me that involuntary swearing, or coprolalia, affects only a minority of people with Tourette syndrome. At 34 years old, however, I possessed the kind of confidence that only genuine ignorance can produce.

I don’t remember the documentary’s title. I don’t remember who made it, where it was filmed, or even what network aired it. What I remember, more than forty years later, is one interview.

The interviewer had Tourette syndrome. So did the two children sitting across from him.

At first nothing seemed unusual. The interviewer asked a question while sitting almost perfectly still. One of the children answered just as calmly. Then something strange happened. As soon as the child began speaking, the interviewer started blinking, shrugging, grimacing, and making the small involuntary sounds characteristic of Tourette syndrome. When the child finished, the interviewer became quiet again, and the child immediately resumed ticcing. The conversation continued that way for several minutes. Whoever was listening displayed the tics. Whoever was speaking seemed, at least temporarily, to lose them. It looked as though the symptoms themselves had impeccable manners, politely waiting for one person to finish before interrupting the next.

The entire classroom laughed.

Not because anyone was mocking the children. We laughed because the timing was so absurdly perfect that it almost looked rehearsed. Even the interviewer seemed amused. Then the lights came back on, the television was rolled out of the room, and we all wandered off to our next classes, convinced we’d just watched an interesting documentary about a rare neurological disorder.

I hadn’t.

I’d watched the opening scene of a mystery that would quietly follow me for the next three decades.

Years later, medical school supplied part of the answer. Patients with Tourette syndrome often describe an uncomfortable sensation that builds until a tic finally occurs, producing a brief sense of relief. One patient explained it to me in a sentence I’ve never forgotten.

“It’s like trying not to sneeze.”

Everyone understands that feeling. You can postpone a sneeze for a while. You can distract yourself. You can fight it with sheer determination. Ironically, the harder you try not to sneeze, the more your attention becomes consumed by the effort. Eventually, the sneeze wins.

That explained why someone speaking might temporarily tic less. Concentrating on a conversation could redirect attention away from the mounting urge. But it still didn’t explain what I had seen. The interviewer hadn’t stopped having Tourette syndrome while he was talking. The children hadn’t recovered whenever they answered. Something else had happened in that room, something I couldn’t explain.

For years I assumed it would remain one of those small medical curiosities that never quite finds an answer. Instead, it kept showing up.

Sometimes it appeared in a patient whose symptoms refused to follow the rules. Sometimes it emerged from a neurology journal or a psychology textbook. Eventually it led me into the Salem witch trials, false memories, mass psychogenic illness, and an emerging branch of neuroscience that argued something almost heretical: the brain isn’t simply observing the world. Much of the time, it’s predicting it.

At first those subjects seemed to have nothing in common. One involved tics, another witches, another courtroom testimony, another mysterious epidemics. Yet every time I stumbled across one of them, I found myself thinking back to that classroom in 1997.

The question itself slowly changed. It was no longer, “Why did those three people seem to exchange their tics?” It became something much larger. How much of what we experience comes directly from the world and how much comes from the story our nervous systems have already begun telling about it?

As Oliver Sacks wrote, “To restore the human subject at the center, we must deepen a case history into a narrative.”² Looking back now, I think that’s exactly what happened to me. I thought I was watching a documentary about Tourette syndrome.

Instead, I was watching the first chapter of a forty-year lesson in how the human mind makes sense of reality.

The Brain Never Stops Explaining

For years I assumed the mystery from that Tourette documentary would eventually be solved by neuroscience. Somewhere, I imagined, there had to be a paper explaining exactly what I’d seen. Perhaps it involved dopamine, the basal ganglia, or some elegant neural circuit nobody had yet explained to me. Medicine has a reassuring habit of believing that every mystery has a mechanism if we’re patient enough to find it.

Then I became a psychiatrist.

Psychiatry has a way of humbling that kind of confidence. Every patient arrives with symptoms, but almost every patient also arrives with an explanation. The teenager who couldn’t finish homework believed he was lazy. The executive who misplaced a familiar name was convinced she had Alzheimer’s disease. The college student whose first panic attack struck in a shopping mall was certain he was dying of a heart attack. Before I ever met them, their minds had already connected the dots into a story that felt perfectly logical.

One family taught me just how misleading those stories can be. They described a boy who, they insisted, “couldn’t pay attention to anything.” Homework was a nightly battle, he never brushed his teeth, rarely bathed, chores never got finished, and dinner required constant reminders to stay seated. Then, almost as an afterthought, they mentioned that he’d recently spent an entire Saturday building a Lego city that covered the family room floor. He hadn’t needed encouragement, hadn’t wandered away, and hadn’t even noticed the time passing.

The problem wasn’t that he couldn’t pay attention. It was that he couldn’t decide what deserved his attention. That distinction changed everything.

As William James observed more than a century ago, “My experience is what I agree to attend to.”³ The longer I practiced, the more that sentence explained. Attention doesn’t merely determine what we notice. It shapes what we remember, what we fear, and eventually what we believe.

The same lesson kept appearing elsewhere. Patients with Parkinson’s disease who froze in empty hallways sometimes walked normally once simple lines were placed on the floor. People who stutter in conversation often sing fluently. Individuals with ADHD who can’t survive ten minutes of homework may spend an entire afternoon happily absorbed in something they love.⁴⁻⁶

• Many people with ADHD demonstrate extraordinary concentration when an activity is genuinely rewarding.⁴
• Visual cues can significantly improve walking in some patients with Parkinson’s disease.⁵
• People who stutter often sing far more fluently than they speak.⁶

The longer I practiced psychiatry, the less interested I became in symptoms themselves and the more interested I became in the explanations surrounding them. It slowly dawned on me that the mind isn’t content to experience the world. It insists on explaining it, often long before all the evidence has arrived.

That didn’t solve the mystery from 1997. It made it bigger.

Because if one mind can build a convincing explanation from incomplete information, what happens when an entire community does the same thing?

When Stories Become Contagious

The question that began with three people in a Tourette documentary eventually led me somewhere I never expected to go.

Salem.

Not because I had a particular interest in colonial America, and certainly not because I believed in witches. I went there because I was looking for another example of intelligent people witnessing the same unexplained events and arriving at conclusions that, centuries later, seem almost impossible to understand.

It’s comforting to imagine we would have been the skeptics. We picture ourselves quietly rolling our eyes while neighbors accused one another of witchcraft, wondering how otherwise sensible people could believe something so extraordinary. Some of us blamed the patriarchy. Some of us blamed ergot poisoning.

History is rarely that generous.

The Salem witch trials didn’t begin with executions. They began with uncertainty. A handful of young girls developed disturbing behaviors that no one could explain. Physicians reportedly found no obvious medical illness. Ministers, parents, and neighbors searched desperately for an answer, and in a deeply religious Puritan community one explanation already existed, waiting to be used.

Witchcraft.

Once that explanation took hold, every strange behavior became another piece of evidence. Every accusation reinforced the last one. Every denial sounded suspicious. Looking back, it’s tempting to ask how so many people could have believed something so implausible. The better question may be how difficult it would have been not to believe it once everyone around you accepted it as reality.

As Voltaire wrote, “Those who can make you believe absurdities can make you commit atrocities.”⁷ Our minds dislike uncertainty. An unanswered question is psychologically uncomfortable. A convincing explanation, even a wrong one, offers relief.

• More than 200 people were accused during the Salem witch trials.⁸
• Twenty people were executed before the panic subsided.⁸
• No credible physical evidence of witchcraft was ever produced.⁸

What fascinates me about Salem isn’t the superstition. It’s the humanity. These weren’t comic-book villains roaming the countryside looking for innocent victims. They were frightened parents, ministers, physicians, judges, and neighbors trying to understand events that made no sense. Surrounded by the same conversations, fears, and assumptions, I suspect most of us would have reached remarkably similar conclusions.

Psychiatry has made me much less confident that I would have been the lone skeptic.

I’ve watched families quietly become convinced that one child is “the problem,” until every forgotten chore, every sarcastic remark, and every slammed door becomes fresh confirmation. I’ve seen workplaces decide one employee is impossible to work with, after which every interaction is interpreted through that single conclusion. Once a shared explanation takes hold, new information rarely arrives as neutral evidence. It arrives already shaped by the story everyone believes.

The Salem witch trials stopped looking to me like an embarrassing historical curiosity. They started looking like a very human one. And that raised another unsettling possibility. If stories can reshape how communities interpret events, could they also reshape what people remember?

The Memories We Build

If Salem taught me that groups can come to believe extraordinary things, another chapter of American history forced me to ask an even more uncomfortable question. What if they could sincerely remember things that never happened?

For most of my life, I thought memory worked something like a filing cabinet. Experiences went in, the brain stored them, and years later we pulled them back out more or less intact. Sure, we forgot details. Dates got fuzzy. Names disappeared. But I assumed the basic event itself stayed put. Psychologists eventually demonstrated just how wrong that assumption was.

Beginning in the 1970s and accelerating through the 1980s and 1990s, researchers like Elizabeth Loftus repeatedly showed that memory is surprisingly easy to reshape. Ask leading questions, repeat a suggestion often enough, mix imagination with genuine recollection, and perfectly intelligent people can become deeply confident about events that never occurred. The memories aren’t lies. They’re experienced as completely real because, to the person remembering them, they are.⁹

That discovery arrived at almost the same moment America became consumed by one of its strangest moral panics.

The McMartin Preschool trial began with allegations that children had been abused at a daycare center in California. As investigators searched for answers, the accusations became increasingly extraordinary. Tunnels beneath the school. Secret rituals. Flights in hot-air balloons. Animal sacrifices. Thousands of alleged victims. Yet after years of investigations, enormous expense, and the longest criminal trial in American history at the time, no physical evidence supporting those claims was ever found.¹⁰

Looking back, it’s easy to laugh at the absurdity. People didn’t laugh then.

Parents were terrified. Investigators believed they were protecting children. Therapists believed they were uncovering hidden trauma. Reporters believed they were exposing a vast conspiracy. Almost everyone involved thought they were doing the right thing. The tragedy wasn’t that evil people fooled everyone else. It was that ordinary people, acting with good intentions, gradually reinforced one another’s certainty until doubt became almost impossible.

• The McMartin Preschool case lasted nearly seven years.¹⁰
• It became the longest and most expensive criminal trial in American history at that time.¹⁰
• No convictions were ever obtained.¹⁰

The more I read about McMartin, the less it resembled an isolated legal disaster. It looked remarkably similar to Salem. Different century. Different vocabulary. Same human machinery. Faced with uncertainty, people searched for an explanation. Once that explanation took hold, every new piece of information was interpreted through it.

That realization changed the way I thought about memory. Remembering isn’t like opening a filing cabinet. It’s more like telling yourself a story over and over again. Each retelling preserves most of the plot, but it also quietly edits the details. New information slips in. Old details fade. Certainty grows even as accuracy sometimes declines.

As Arthur Miller, whose The Crucible transformed Salem into a warning about every era, understood so well, societies don’t simply pass stories from one generation to the next. They also teach us which stories we’re expected to believe.⁵. By now, the question that had begun with Tourette syndrome had changed once again. Maybe the most remarkable thing about the mind isn’t that it remembers. Maybe it’s that it rewrites.

When the Body Believes the Story

By the time I finished reading about the McMartin Preschool case, the question that had begun with that Tourette documentary had changed yet again. If attention can be shaped, and memories can be reshaped, where does the process stop? My instinctive answer was the body.

Surely memories could be wrong while muscles, lungs, skin, and nerves remained stubbornly honest. Then I stumbled across mass psychogenic illness.

I almost skipped the chapter. The name sounded terrible, conjuring images of people pretending to be sick or doctors dismissing suffering with the phrase, “It’s all in your head.” Instead, I found researchers describing something far more interesting. The symptoms were entirely real. The headaches, dizziness, nausea, tremors, weakness, even paralysis were genuine. What wasn’t real was the danger people believed had caused them.

As Robert Bartholomew, one of the leading researchers in the field, wrote, “Mass psychogenic illness is a normal response to abnormal stress.”¹¹ I love that definition because it removes the blame. These aren’t irrational people. They’re ordinary nervous systems doing exactly what evolution encouraged them to do. When the choice is between overreacting to a possible threat and ignoring a real one, evolution has generally favored false alarms.

The medical literature is filled with stories that sound almost fictional. Workers smell an unfamiliar odor, and dozens become ill before investigators discover there was no toxic chemical. Students begin coughing or fainting, and the symptoms spread through an entire school despite exhaustive testing finding no infection. Buildings are evacuated. Emergency rooms fill. Investigators search for poisons, viruses, or gas leaks and find...nothing.

• More than 2,000 outbreaks of mass psychogenic illness have been described in the medical literature.¹¹
• Cases have occurred on every inhabited continent over several centuries.¹¹
• The symptoms are genuine even when no toxin or infectious disease is ever identified.¹¹

One outbreak, however, stayed with me. In 1962, at a girls’ boarding school in what is now Tanzania, three students began laughing. Then more students laughed. Soon neighboring schools were affected. Some girls laughed for hours, others for days. Schools closed, thousands of people were eventually involved, and the epidemic slowly faded away as mysteriously as it had begun.¹²

The first time I read that story, I laughed myself. Not because it was funny. Because it sounded impossible. Then I thought back to that classroom in 1997. Maybe impossible wasn’t the right word.

The saying usually attributed to Mark Twain came to mind: “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” Whether Twain actually said those words is almost beside the point. Medicine has taught me that certainty is often far more dangerous than curiosity.

Somewhere along the way, I’d stopped asking whether the mind could influence the body. It clearly could. The real mystery had become how a lifetime of expectations, attention, and experience could quietly shape what the body itself was capable of feeling. That question would eventually lead me to one of the most surprising ideas in modern neuroscience.

The Brain’s Best Guess

By this point, the question that had started in a college classroom had led me through neurology, psychiatry, colonial history, courtroom testimony, and public health. Everywhere I looked, the same pattern kept reappearing. Attention influenced experience. Shared narratives influenced belief. Memory wasn’t nearly as permanent as I’d imagined. Even the body seemed capable of responding to expectations in ways that felt almost unbelievable. It was as though I had spent years collecting pieces from different puzzles, only to discover they all belonged in the same box.

The final piece came from neuroscience.

Like most people, I’d always assumed perception worked in the obvious direction. Light entered the eyes, sound entered the ears, and the brain patiently assembled those raw materials into an accurate picture of reality. It seemed so self-evident that I never thought to question it. After all, that’s how cameras work.

Modern neuroscience suggests our nervous systems do something much stranger.

Rather than waiting passively for information to arrive, the brain is constantly making predictions about what it’s about to see, hear, and feel. Incoming sensory information is enormously important, but instead of creating perception from scratch, it continually updates those predictions, correcting them whenever the outside world disagrees. In other words, perception is less like reading a book one word at a time and more like finishing another person’s sentences. Most of the time we’re right. Occasionally we’re spectacularly wrong.

When I first encountered that idea, I hated it. Not because the evidence was weak, but because it overturned something I’d never realized I believed. I had always assumed my experience of the world began with reality itself. These researchers were arguing that experience begins with a prediction, and reality spends the next fraction of a second negotiating with it.

As neuroscientist Anil Seth likes to say, “We don’t just perceive the world. We actively generate it.”¹³ He has also described perception as a “controlled hallucination,” a phrase that sounds outrageous until you see the evidence. Consider the famous rubber hand illusion. A volunteer hides one hand while an artificial rubber hand is placed on the table in front of them. Both hands are stroked in exactly the same way, and within minutes many people begin to experience the fake hand as their own. Threaten it with a hammer and they flinch. Their heart rate rises. Some instinctively pull away. Intellectually they know it isn’t their hand. Their nervous system has simply reached a different conclusion.

The same thing happens after amputations. People often continue feeling an itch in a foot that’s no longer there or pain in fingers that were lost years earlier. The missing limb hasn’t changed. The brain’s internal map of the body hasn’t caught up yet. Expectations, it turns out, can outlive anatomy.

• Many amputees continue experiencing vivid sensations in missing limbs.¹⁴
• The rubber hand illusion can temporarily convince healthy volunteers that an artificial hand belongs to them.¹⁵
• Placebos and nocebos demonstrate that expectations alone can measurably influence pain, nausea, movement, and many other physical symptoms.¹⁶

The placebo effect has always amused me because it’s probably the best-known phenomenon in medicine and one of the least understood. We often talk about placebos as though they prove symptoms were imaginary all along. In reality, they demonstrate exactly the opposite. Give someone a sugar pill while convincingly describing it as a powerful pain medication, and measurable changes occur in the nervous system. Endorphins are released, pain-processing circuits become less active, and many people genuinely feel better. The nocebo effect simply tells the same story in reverse. Warn people to expect side effects, and they’re substantially more likely to experience them, even when the pill itself is completely inert. Expectations don’t create fake symptoms. They can create real biology.

Reading all of this, I found myself thinking once again about those three people in the Tourette documentary. I’d spent decades assuming the mystery was how their symptoms seemed to take turns appearing. Now I wondered whether I’d been looking at the wrong mystery all along. Perhaps the remarkable thing wasn’t that the nervous system could be influenced by attention, expectation, and context. Perhaps the remarkable thing was that I’d ever assumed it couldn’t.

That realization changed the way I thought about far more than Tourette syndrome. It changed the way I thought about Salem, McMartin, the laughter epidemic in Tanzania, placebo effects, anxiety disorders, trauma, and countless patients I’d seen over the years. They no longer looked like unrelated curiosities. They looked like different windows into the same extraordinary organ, one that spends every waking moment making its best guess about the world and then quietly revising that guess as new information arrives.

Once I saw that pattern, I couldn’t stop seeing it. And then the pandemic arrived.

The World’s Largest Psychology Experiment

If someone had asked me ten years ago whether billions of people could experience the same event and emerge with their nervous systems subtly changed, I probably would have smiled politely and changed the subject.

Then came COVID-19.

I’m not talking about whether the virus was real. It was devastatingly real. Millions of people died. Intensive care units overflowed. Some hospitals parked refrigerated trucks outside because there simply wasn’t enough room for the dead. Families said goodbye through iPads while physicians, nurses, respiratory therapists, and countless others carried burdens that few people outside healthcare will ever fully understand. None of what follows diminishes that tragedy.

What fascinated me, both as a psychiatrist and someone trained in public health, was something else. I watched the world’s largest prediction machine suddenly lose its ability to predict.

Almost overnight, daily life became a series of unanswered questions. Was it safe to buy groceries? Could you hug your parents? Would masks help? Were the vaccines working? Was that cough allergies, a cold, or the beginning of something much worse? Every phone buzzed with another alert. Every television featured another panel of experts. People who had never given epidemiology a second thought suddenly found themselves discussing viral transmission, exponential growth, and R numbers over dinner.

As Daniel Kahneman observed, “Nothing in life is as important as you think it is while you are thinking about it.”¹⁷ For months, then years, nearly everyone on Earth was thinking about the same thing. Am I safe?

Brains become better at whatever they practice. Pianists practice scales. Basketball players practice free throws. During the pandemic, billions of nervous systems spent day after day practicing vigilance. Every headline invited us to search for danger. Every conversation encouraged us to imagine the next possible threat. Every uncertainty demanded another prediction.

As Mike Tyson famously said, “Everybody has a plan until they get punched in the mouth.” COVID punched the entire planet in the mouth. Once survival became the priority, our nervous systems responded exactly as evolution had prepared them to respond: they became exquisitely sensitive to anything that might signal danger.

• Anxiety and depressive disorders increased dramatically around the world.¹⁸
• Children and adolescents experienced some of the largest increases in anxiety, depression, and social isolation.¹⁸
• Loneliness, sleep disruption, and psychological distress rose across nearly every age group.¹⁸

What interested me most, however, happened after the worst of the pandemic had passed. Patients gradually stopped talking about COVID itself, but they didn’t stop talking about danger. Artificial intelligence replaced variants. Climate change replaced case counts. Inflation replaced hospitalization rates. School shootings, politics, war, and the economy each took their turn. The subjects changed, but the emotional rhythm of the conversations barely changed at all. Many patients described a persistent feeling that they simply couldn’t relax anymore, as though lowering their guard for even a moment might allow the next catastrophe to slip past unnoticed.

I’d heard that feeling before. Combat veterans sometimes continue scanning rooftops years after returning home. Survivors of abusive relationships may startle at sounds nobody else notices. Parents whose child was once critically ill often continue checking on them in the middle of the night long after the crisis has passed. None of these people are irrational. Their nervous systems learned a lesson that was extraordinarily useful at the time.

The difficulty is that nervous systems don’t automatically recognize when the lesson is over.

Seen this way, the pandemic wasn’t simply one of the largest public health crises in modern history. It also became one of the largest psychological experiments in history. Never before had billions of people spent years rehearsing uncertainty while connected by twenty-four-hour news cycles and social media algorithms that rewarded fear, outrage, and constant vigilance. We learned an enormous amount about viruses and vaccines. We also learned something about ourselves.

If experience can teach the brain to expect danger, experience can also teach it something else.

Changing the Story

One of the most hopeful discoveries in modern neuroscience is also one of the least dramatic: the adult brain never really stops changing. Today we hear the word neuroplasticity so often that it’s almost become background noise, but when I was in medical school many of us were still taught that, by adulthood, the brain was essentially finished wiring itself. Children learned. Adults simply lived with whatever circuitry they had managed to build.

Everything I’d been reading suggested otherwise.

The Tourette documentary, the Salem witch trials, the McMartin Preschool case, mass psychogenic illness, predictive processing, placebo effects, even the lingering hypervigilance left behind by the pandemic were no longer separate stories. They all described the same remarkable ability from different angles. The nervous system is constantly learning from experience. Most of the time that’s exactly what keeps us alive. The difficulty comes when yesterday’s successful adaptations quietly become today’s unnecessary suffering.

That realization changed the way I think about psychiatry. Patients often arrive convinced that anxiety, depression, obsessive thinking, or trauma have become permanent parts of who they are. I understand why. Depression whispers that nothing will ever improve. Anxiety insists the danger isn’t over. Trauma has an extraordinary ability to convince the nervous system that yesterday is still happening today. But if experience can strengthen those pathways, experience can strengthen different ones as well.

I often think of the process as walking through a forest. The first time you cross the woods, you leave almost no trace. Walk the same route every day for years and eventually a path appears. Keep using it and the trail becomes easier to follow than the surrounding underbrush. Before long, you stop choosing the path because the path has begun choosing you. The encouraging part is that forests don’t stay frozen forever. New trails can be made. At first they feel awkward and inefficient. Therapy feels unnatural. Meditation feels frustrating. Exercise feels exhausting. Reaching out to another person instead of withdrawing can feel almost impossible. That’s exactly what we’d expect. The old trail has been reinforced thousands of times. The new one is only beginning.

As Victor Borge observed, “Laughter is the shortest distance between two people.” I’ve always liked that quotation because it reminds me that brains don’t change in isolation. Every meaningful relationship leaves fingerprints on the nervous system. Good therapists, patient teachers, loving parents, trusted friends, and supportive partners are all quietly helping another human being build new pathways, often without realizing they’re doing anything extraordinary.

• London taxi drivers develop measurable enlargement of brain regions involved in spatial navigation after years of memorizing the city’s streets.¹⁹
• Cognitive behavioral therapy produces measurable changes in brain activity as symptoms improve.²⁰
• Mindfulness, regular exercise, and healthy sleep are all associated with measurable changes in brain structure and function.²¹

One of the great privileges of psychiatry is watching those new trails slowly emerge. I’ve seen children who couldn’t remain seated long enough to finish a classroom lesson grow into successful engineers. I’ve watched patients whose panic attacks once kept them trapped at home eventually board airplanes, give public lectures, get married, raise children, and forget there was ever a time they believed those things were impossible. None of those people changed overnight, and none succeeded because someone persuaded them simply to “think positive.” They changed because their nervous systems kept doing what healthy nervous systems have always done. They practiced. They adapted. They learned.

Looking back now, I no longer think that documentary in 1997 was really about Tourette syndrome. It was about something much larger, although it took me four decades to recognize it. The most hopeful lesson in all of neuroscience isn’t that the brain can change. It’s that it never completely stops.

The Story We Tell Ourselves

Every article eventually reaches the point where the author has to admit what he’s really been writing about. This is that point.

When I first watched that documentary, I thought I was learning about Tourette syndrome. Then I became convinced it was really about attention. A few years later I thought it was about memory. Then came Salem, McMartin, mass psychogenic illness, predictive processing, placebo effects, and the pandemic. For a long time, those subjects seemed only loosely connected, as though I were wandering through different wings of the same museum without realizing they all belonged to a single exhibit.

Looking back, I think they were all asking the same question.

How much of what we experience comes directly from the outside world, and how much is shaped by the remarkable organ trying to make sense of it?

The answer, I suspect, is both. Reality exists independent of us. Viruses don’t care whether we believe in them. Gravity doesn’t consult our opinions before we fall. Trauma is real. Joy is real. Love is real. Yet none of us encounters those realities directly. Every sight, sound, memory, fear, hope, and relationship passes through a nervous system that has spent a lifetime learning what matters, what is dangerous, what can be ignored, and what deserves immediate attention. Most of the time that system serves us astonishingly well. It allows us to navigate a world that contains far more information than we could ever consciously process. Occasionally, however, it fills in the blanks a little too quickly or clings to yesterday’s lessons long after the world has changed.

That, more than anything else, has changed the way I practice psychiatry. Diagnoses matter. Medications matter. Neuroscience matters. But beneath all of them is a quieter question that I find myself asking almost every day: What else might be true? Sometimes the answer changes a diagnosis. Sometimes it changes a marriage. Sometimes it changes the way someone understands themselves after carrying the same painful explanation for decades.

As David Foster Wallace said in his famous commencement address, “Learning how to think really means learning how to exercise some control over how and what you think.” He wasn’t talking about predictive processing, but he understood something every psychiatrist eventually learns. Our first interpretation isn’t always our best one. Curiosity is often a better guide than certainty.

• The nervous system is constantly updating its internal model of the world as new information arrives.¹³
• Attention, memory, emotion, and expectation all shape what we consciously experience.¹³⁻²¹
• Because those systems remain plastic throughout life, our interpretations can continue changing too.¹⁹⁻²¹

I still think about those three people with Tourette syndrome from time to time. I can still picture the interviewer, the two children, and an entire college classroom laughing because the timing of their tics seemed too perfect to be real. At the time, I thought I’d witnessed a strange neurological curiosity. It never occurred to me that the real mystery wasn’t sitting in front of the camera.

It was sitting in the audience.

For more than forty years, that brief documentary quietly sent me from neurology to psychiatry, from colonial Massachusetts to modern courtrooms, from public health to neuroscience, asking versions of the same question over and over again. I never found a single elegant answer, and I’m no longer sure one exists. Instead, I found something I think is more interesting: a growing appreciation for just how creative, adaptable, resilient, and occasionally misleading the human mind can be.

We spend our lives believing we’re simply observing the world. Perhaps we’re doing something far more remarkable. Perhaps, moment by moment, we’re learning how to understand it.

If you enjoyed this article, I’d really appreciate it if you’d click Subscribe, share it with someone who enjoys asking uncomfortable questions, and leave a comment below. Every subscription, share, and conversation helps these ideas reach more people. After all, if our minds are constantly learning from the stories we tell ourselves, maybe it’s worth making sure we’re telling better ones.

Notes & Sources

1. Leckman JF, Bloch MH, King RA, Scahill L. Phenomenology of Tics and Natural History of Tic Disorders. Advances in Neurology. 2006.

2. Sacks O. An Anthropologist on Mars. Alfred A. Knopf; 1995.

3. James W. The Principles of Psychology. Henry Holt; 1890.

4. Barkley RA. Taking Charge of Adult ADHD. Guilford Press; 2010.

5. Morris ME. Movement Disorders in People With Parkinson Disease: A Model for Physical Therapy. Physical Therapy. 2000.

6. Alm PA. Stuttering in Relation to Anxiety, Temperament, and Personality. International Journal of Language & Communication Disorders. 2014.

7. Voltaire. The Philosophical Dictionary. 1764.

8. Boyer P, Nissenbaum S. Salem Possessed: The Social Origins of Witchcraft. Harvard University Press; 1974.

9. Loftus EF, Ketcham K. Witness for the Defense. St. Martin’s Press; 1991.

10. Nathan D, Snedeker M. Satan’s Silence: Ritual Abuse and the Making of a Modern American Witch Hunt. Basic Books; 1995.

11. Bartholomew RE, Wessely S. “Protean Nature of Mass Sociogenic Illness.” British Journal of Psychiatry. 2002; Bartholomew RE, Radford B. Mysteries of Mass Hysteria. Prometheus Books; 2012.

12. Rankin AM, Philip PJ. “The Tanganyika Laughter Epidemic.” Central African Journal of Medicine. 1963.

13. Seth A. Being You: A New Science of Consciousness. Dutton; 2021.

14. Ramachandran VS, Blakeslee S. Phantoms in the Brain. William Morrow; 1998.

15. Botvinick M, Cohen J. “Rubber Hands ‘Feel’ Touch That Eyes See.” Nature. 1998;391:756.

16. Benedetti F. Placebo Effects. Oxford University Press; 2014.

17. Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux; 2011.

18. World Health Organization. Mental Health and COVID-19: Early Evidence of the Pandemic’s Impact. 2022.

19. Woollett K, Maguire EA. “Acquiring ‘The Knowledge’ of London’s Layout Drives Structural Brain Changes.” Current Biology. 2011.

20. DeRubeis RJ, Siegle GJ, Hollon SD. “Cognitive Therapy versus Medication for Depression: Brain Mechanisms and Clinical Outcomes.” Nature Reviews Neuroscience.

21. Davidson RJ, Goleman D. Altered Traits: Science Reveals How Meditation Changes Your Mind, Brain, and Body. Avery; 2017.

Quotations

• Oliver Sacks — An Anthropologist on Mars.

• William James — The Principles of Psychology.

• Voltaire — The Philosophical Dictionary.

• Mark Twain (quotation commonly attributed; attribution disputed): “It ain’t what you don’t know that gets you into trouble...”

• Robert Bartholomew — Protean Nature of Mass Sociogenic Illness.

• Anil Seth — Being You.

• Daniel Kahneman — Thinking, Fast and Slow.

• Mike Tyson — “Everybody has a plan until they get punched in the mouth.”

• Victor Borge — “Laughter is the shortest distance between two people.”

• David Foster Wallace — This Is Water commencement address.

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A few years later, I picked them up again. They were entirely different books. Of course, they weren’t. I was.

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That became one of the unexpected pleasures of getting older. Books don’t age; readers do. The words remain the same, but our experiences change what we notice. Orwell was no longer writing only about dictatorship. He was writing about language, certainty, and the ease with which people reshape reality. Vonnegut wasn’t simply telling a strange story about time travel. He was exploring trauma, memory, and humanity’s remarkable ability to normalize the unimaginable.

During my undergraduate years, I enrolled in a course on the Holocaust, assuming I already understood the subject. Instead, I encountered entirely new ways of thinking about it. That class introduced me to Leni Riefenstahl’s Triumph of the Will, Tadeusz Borowski, Primo Levi, and other writers who were less interested in recounting history than in understanding how ordinary societies gradually accepted the unacceptable. They weren’t asking how the Holocaust ended. They were asking how it began.

I left that class realizing I had been asking the wrong questions. The pattern continued for years. I was drawn to Terry Gilliam’s Brazil because I loved Monty Python. I remembered the endless ducts, malfunctioning machinery, and absurd bureaucracy. I thought it was surreal comedy. Years later, it looked less surreal.

The same thing happened with Monty Python’s Flying Circus. As a teenager, I laughed at the physical comedy of John Cleese’s “Ministry of Silly Walks” and wonderfully ridiculous sketches like the Society for Putting Things on Top of Other Things. Only much later did I appreciate that much of the comedy was satire aimed at a government that often seemed capable of creating a ministry, committee, or regulation for almost anything. The jokes hadn’t changed. I had.

Looking back, I realized these artists weren’t trying to predict the future. They were paying closer attention to human nature than I was.

The Artists Arrive First

As I reread these books and rewatched these films, I gradually became less interested in their stories than in the people who created them. George Orwell, Charlie Chaplin, Terry Gilliam, Kurt Vonnegut...they all seemed to notice something long before historians had a vocabulary for describing it.

That realization eventually led me to Leni Riefenstahl, a name that still makes many people uncomfortable. Watching Triumph of the Will, I was struck less by Hitler than by the filmmaking itself. The sweeping camera movements, carefully choreographed crowds, dramatic lighting, and heroic angles were undeniably beautiful. Then I caught myself having an unsettling thought: millions of Germans must have found them beautiful, too.

For years I wondered how Riefenstahl could insist she had simply been making art. Eventually I realized that whether she believed her own explanation wasn’t the question that interested me most. What fascinated me was how completely she understood her audience. The film isn’t persuasive because it offers brilliant arguments. It’s persuasive because it makes certainty, unity, and power feel emotionally irresistible. People rarely fall in love with an ideology first. They fall in love with belonging.

Once I saw that, I looked differently at the artists I admired. Chaplin wasn’t merely mocking Hitler, Gilliam wasn’t simply satirizing bureaucracy, and Orwell wasn’t only imagining a dystopian future. They were all paying attention to the emotional climate of a society before anyone could fully explain where it was heading.

My office eventually became another classroom. I suppose that shouldn’t have surprised me. Patients rarely describe dramatic turning points. More often they tell stories of gradual shifts that only become obvious in retrospect. Perhaps societies change the same way. Historians eventually explain what happened, but artists often recognize the feeling first.

• Propaganda succeeds by shaping emotions before it shapes beliefs.³
• Images often persuade more powerfully than arguments alone.⁴
• Great art preserves not only events but also the emotional experience of living through them.⁵

Different Roads to the Same Place

As I continued reading, I noticed that the great novelists of the twentieth century weren’t all describing the same nightmare. They were describing different paths leading toward it. When I was younger, I thought readers were supposed to decide whether George Orwell or Aldous Huxley had been “right.” Was the real danger censorship and surveillance, as Orwell imagined, or endless distraction and comfort, as Huxley feared?

The older I’ve become, the less interesting that debate seems. Neither writer was trying to predict the future. Both were trying to understand people. Orwell worried about fear, propaganda, and the corruption of language. Huxley wondered whether people might simply surrender their curiosity in exchange for comfort. One imagined oppression imposed from above. The other imagined complacency embraced from below. Those aren’t contradictory ideas. They’re complementary observations about human nature.

Reading Ray Bradbury years later, I found myself noticing something I had completely missed before. Fahrenheit 451 isn’t simply about governments burning books. It’s about a society that gradually stops wanting to read them. The tragedy isn’t censorship alone; it’s indifference. Books disappear because people stop valuing them before anyone is forced to surrender them.

Then there’s Sinclair Lewis. The brilliance of It Can’t Happen Here isn’t the plot nearly as much as the title. Every generation convinces itself that authoritarianism belongs somewhere else, to someone else, in another era. Lewis understood that confidence itself can become a dangerous blind spot.

What ties these writers together isn’t that they reached identical conclusions. It’s that they were all paying attention to recurring features of human nature: fear, conformity, distraction, certainty, tribalism, and our remarkable ability to convince ourselves that we’re different from the people who came before us.

As a psychiatrist, I hear that same confidence every day. Patients often describe patterns they never imagined could happen to them—depression, addiction, burnout, the slow collapse of a marriage. The details differ, but the psychology is surprisingly consistent. We all believe we’re the exception until we discover we’re not.

Perhaps that’s why these novels continue to feel contemporary. They aren’t really about politics. They’re about us.

• George Orwell explored the political power of language, surveillance, and fear.⁶
• Aldous Huxley argued that comfort and distraction can become powerful tools of social control.⁷
• Ray Bradbury warned that censorship begins with cultural indifference as much as government prohibition.⁸
• Sinclair Lewis challenged the comforting belief that democracies are automatically immune to authoritarian movements.⁹

When Imagination Became Memory

If Orwell, Huxley, Bradbury, and Lewis asked what might happen, another group of writers no longer had to imagine. They had been there. Reading Primo Levi, Elie Wiesel, Aleksandr Solzhenitsyn, and especially Tadeusz Borowski felt fundamentally different from reading dystopian fiction. These weren’t warnings. They were attempts to describe experiences that seemed almost beyond language.

What surprised me most wasn’t the horror. It was the normality.

I still remember reading Borowski’s This Way for the Gas, Ladies and Gentlemen and waiting for dramatic moments that never quite arrived. Instead, I found prisoners worrying about food, arguing with one another, making jokes, trading favors, falling into routines, and trying to survive one more day. The camps were unimaginably cruel, but they were also filled with ordinary human behavior. Breakfast was still breakfast. Work was still work. Conversations still happened. People adapted because adaptation was the only way to remain alive.

That may have been the most unsettling lesson I learned in college.

I had always imagined history as a series of extraordinary events experienced by extraordinary people. Borowski showed me something much more disturbing. Human beings remain recognizably human even inside circumstances that future generations can scarcely imagine. They still complain, laugh, gossip, make friends, and worry about tomorrow. Ordinary life doesn’t disappear under authoritarianism. It slowly changes shape.

Reading Levi reinforced that idea. His writing is remarkably restrained, almost clinical at times, as though emotional exaggeration would somehow diminish the truth. Wiesel gave voice to the moral devastation that accompanies survival itself. Solzhenitsyn described a different machinery of repression, but one that depended upon many of the same human tendencies: conformity, fear, accommodation, and the gradual acceptance of what had once seemed impossible.

Eventually, these books followed me into my office. I eventually realized I had seen this process before, although in far less dramatic circumstances. Patients rarely describe a single moment when life suddenly became unrecognizable. More often they tell stories of gradual adaptation. Depression narrows life one small decision at a time. Addiction reorganizes priorities almost imperceptibly. An unhealthy relationship slowly redefines what feels normal. Looking backward, the pattern seems obvious. Living through it, almost nothing feels dramatic.

Perhaps that’s why these memoirs continue to haunt me more than any dystopian novel. They remind us that history isn’t experienced as history. It’s experienced as everyday life.

• Tadeusz Borowski portrayed concentration camp life through ordinary routines rather than extraordinary heroism, challenging conventional narratives of the Holocaust.¹⁰
• Primo Levi emphasized the gradual erosion of moral and psychological boundaries under extreme conditions.¹¹
• Elie Wiesel explored the spiritual and ethical consequences of surviving genocide.¹²
• Aleksandr Solzhenitsyn documented how repression becomes normalized through everyday institutional life.¹³

The Tyranny of the Ordinary

One of the things that surprised me most was how often artists portrayed authoritarianism not through violence, but through bureaucracy. That may sound strange until you read Franz Kafka.

When I first picked up The Trial, I wondered why people regarded it as one of the great novels of the twentieth century. Josef K. is arrested without explanation and spends the rest of the book wandering through a legal system where every office leads to another office, every answer produces another question, and nobody—not even the officials—seems to understand the rules. Reading it is quietly exhausting.

Eventually I realized that was exactly what Kafka wanted me to feel. The novel isn’t frightening because of physical danger. It’s frightening because uncertainty slowly becomes ordinary. That realization changed the way I watched Terry Gilliam’s Brazil. The first time I saw it, I remembered the absurd ductwork, malfunctioning machinery, and endless forms that seemed to require still more forms. Years later I realized Gilliam wasn’t simply exaggerating bureaucracy. He was showing what happens when institutions become so consumed with procedure that they forget the people they were created to serve.

The same thing happened when I revisited Monty Python’s Flying Circus. As a teenager, I laughed at John Cleese’s “Ministry of Silly Walks” and wonderfully ridiculous sketches like the Society for Putting Things on Top of Other Things because they were delightfully absurd. Only years later did I appreciate that much of the humor was aimed at a government capable of creating a ministry, committee, or regulation for almost anything. The comedy worked because there was just enough truth beneath the exaggeration.

That became another recurring lesson of this essay. The artists hadn’t changed. I had. Over the years, my patients have taught me that patients often laugh just before they say something profoundly painful. Humor creates enough distance for people to acknowledge truths that would otherwise be difficult to face. Perhaps satire serves the same purpose for societies. It allows artists to point toward uncomfortable realities years before the rest of us are ready to recognize them.

• Franz Kafka’s The Trial remains one of literature’s defining portraits of bureaucratic alienation.¹⁴
• Terry Gilliam has acknowledged Kafka’s influence on Brazil.¹⁵
• Monty Python’s Flying Circus frequently satirized the expanding complexity of British governmental and social institutions.¹⁶

Seeing Patterns

By this point, I began noticing something else. None of these artists seemed particularly interested in predicting the future. They were paying attention to patterns.

One lesson clinical practice keeps reinforcing is that idea feels remarkably familiar. Patients rarely arrive in my office because one catastrophic event suddenly changed everything. More often, they describe dozens of seemingly insignificant shifts that only make sense when viewed together. Sleep becomes a little less refreshing. Drinking becomes a little more frequent. One avoided social event becomes several. An occasional argument slowly becomes the way a couple communicates. Individually, each change seems trivial. Together, they become a pattern.

Artists often work the same way. Orwell noticed how language shapes thought. Huxley worried that comfort could become a substitute for curiosity. Kafka saw what happens when institutions become detached from the people they serve. Chaplin recognized that powerful men often look much less powerful once they’re laughed at. Gilliam exposed the absurdity that emerges when bureaucracy begins existing for its own sake. Borowski showed how ordinary people adapt to extraordinary circumstances until the extraordinary begins to feel almost routine.

None of them was describing exactly the same problem. They were describing recurring features of human nature.

Perhaps that’s why their work continues to feel contemporary decades later. Governments change. Technology changes. Clothing changes. Human beings don’t change nearly as much as we like to believe. We still seek certainty. We still conform to groups. We still adapt to our surroundings with astonishing speed. We still tell ourselves stories that make the present feel reasonable.

That realization has changed the way I read. I no longer ask whether an author correctly predicted the future. I’m much more interested in what they noticed about people that I had overlooked.

Perhaps that’s what great art has always done. It teaches us to recognize patterns before history gives them names.

• Great artists often identify recurring psychological patterns rather than making literal predictions.¹⁷
• Human beings naturally organize experience through narratives and pattern recognition.¹⁸
• The emotional and social dynamics explored by classic literature remain remarkably stable across generations.¹⁹

Why I Still Read Them

Every few years I find myself pulling one of these books off the shelf again. I don’t reread them because someone assigned them. There isn’t an exam waiting for me or a paper due next week. I already know how every story ends. That’s never been the point.

I reread George Orwell because I’m curious what I’ll notice this time. I return to Kurt Vonnegut because I’m still amazed that someone could write so humorously about unimaginable suffering. I revisit Primo Levi, Tadeusz Borowski, and Aleksandr Solzhenitsyn because they remind me that history is never an abstraction. It is always experienced one ordinary day at a time.

The same thing happens with films. Every time I watch Terry Gilliam’s Brazil, another joke lands that I completely missed years before. Every time I revisit Monty Python, I laugh for different reasons. As a teenager, I thought the sketches were simply absurd. Now I appreciate that they were observations disguised as comedy.

Perhaps that’s one of the unexpected gifts of growing older. The books haven’t changed. I have. That’s also why I still believe students should read Orwell, Vonnegut, and the other writers I resisted when they were assigned to me. Many will read them only because they have to. They’ll finish the assignment, take the test, and move on, just as I did.

That’s perfectly all right. The books are patient. They’ll still be there twenty years later, waiting for readers who have accumulated enough life to finally recognize what the authors were trying to show them.

As a psychiatrist, I think about that often. People come to my office hoping I’ll explain why their lives unfolded the way they did. Sometimes we find an answer. More often, we simply discover patterns that had been present all along but remained invisible while they were living them. Perhaps that’s what the greatest artists have always offered us. Not predictions. Perspective.

The older I become, the less interested I am in finding books that tell me what to think. I’m far more grateful for the ones that quietly teach me how to see.

Notes and Sources

1. Orwell, George. Nineteen Eighty-Four. Secker & Warburg, 1949.

2. Vonnegut, Kurt Jr. Slaughterhouse-Five. Delacorte Press, 1969.

3. Riefenstahl, Leni. Triumph of the Will. Reich Ministry of Public Enlightenment and Propaganda, 1935.

4. Chaplin, Charlie. The Great Dictator. United Artists, 1940.

5. Brooks, Mel. The Producers. Embassy Pictures, 1967. See also interviews discussing comedy as resistance to tyranny.

6. Kafka, Franz. The Trial. Published posthumously, 1925.

7. Gilliam, Terry. Brazil. Universal Pictures, 1985.

8. Chapman, Graham; Cleese, John; Gilliam, Terry; Idle, Eric; Jones, Terry; Palin, Michael. Monty Python’s Flying Circus. BBC Television, 1969–1974.

9. Lewis, Sinclair. It Can’t Happen Here. Doubleday, Doran & Company, 1935.

10. Huxley, Aldous. Brave New World. Chatto & Windus, 1932.

11. Bradbury, Ray. Fahrenheit 451. Ballantine Books, 1953.

12. Levi, Primo. If This Is a Man (Survival in Auschwitz). De Silva, 1947.

13. Borowski, Tadeusz. This Way for the Gas, Ladies and Gentlemen. Państwowy Instytut Wydawniczy, 1948.

14. Wiesel, Elie. Night. Les Éditions de Minuit, 1958.

15. Solzhenitsyn, Aleksandr. The Gulag Archipelago. YMCA Press, 1973.

16. Arendt, Hannah. Eichmann in Jerusalem: A Report on the Banality of Evil. Viking Press, 1963.

17. Kahneman, Daniel. Thinking, Fast and Slow. Farrar, Straus and Giroux, 2011.

18. Frankl, Viktor E. Man’s Search for Meaning. Beacon Press (English edition), 1959.

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Growing up Jewish, I don’t remember a time when the Holocaust wasn’t quietly present. No one sat me down for formal lessons about genocide. It simply existed in the background of life, woven into synagogue services, Hebrew school, Confirmation Class for my synagogue (in the 1970’s we were instructed how to avoid all the cults trying to convert Jews), documentaries on television, and the occasional photograph in a history book that seemed far more disturbing than the surrounding pages. Like many Jewish children of my generation, I learned the phrase Never Again long before I understood exactly what had happened the first time.

Some of my strongest memories come from the annual Passover Seders at my grandfather’s house. The dining room was loud, filled with overlapping conversations, children wandering in and out, and adults who assumed we weren’t paying attention. Every so often, though, a sentence would rise above the noise and stay with me. “Everyone wants to kill the Jews”.

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Later, perhaps during an entirely different conversation, another voice would answer,

“You can’t blame that on the Jews.”

I doubt anyone intended those comments to become childhood memories, but they did. Long before I understood the history behind them, I understood that the adults around the table viewed antisemitism not as an ancient tragedy but as something that never entirely disappeared.

As a child, I imagined history unfolding in dramatic chapters. There was a beginning, a middle, and an unmistakable end. The Holocaust fit neatly into that pattern. Good people eventually defeated bad people, the camps were liberated, and Never Again meant humanity had learned its lesson.

Psychiatry slowly dismantled that way of thinking.

After more than twenty years of listening to patients tell me about their lives, I’ve become suspicious of dramatic turning points. Most people cannot identify the day their depression began, when anxiety quietly started shrinking their world, or when an occasional drink became a dependence. Looking back, those changes often seem obvious. Living through them, they rarely do. They accumulate so gradually that, before long, the new normal simply feels normal.

The more history I read, the more familiar that pattern became. We remember the Holocaust through barbed wire, cattle cars, crematoria, and skeletal survivors, but those were the end of the story, not the beginning. The beginning looked ordinary. It looked like elections, newspapers, economic anxiety, conspiracy theories, bureaucratic rules, and neighbors who slowly learned to speak about one another differently. No single step foretold Auschwitz. Seen together, those steps quietly altered what people considered imaginable.

Medicine teaches the same lesson. Heart attacks begin years before the ambulance arrives. Cirrhosis begins long before liver failure. Suicide rarely begins on the day someone dies. By the time a crisis becomes unmistakable, the underlying process has usually been unfolding for years. Reading Primo Levi, Viktor Frankl, and Aleksandr Solzhenitsyn, I found myself recognizing that same rhythm. Catastrophes dominate history books because they are impossible to ignore. The quieter years that made them possible are easier to overlook.

What fascinates me is not whether history repeats itself, but how ordinary people gradually accept ideas that would once have shocked them. How does the unthinkable become familiar? What happened to Israel? To Zionism? How is Jewish history able to countenance their treatment of the indigenous Palestinians and others in Lebanon and Syria? Those questions have occupied historians for generations. They have gradually become some of the most interesting questions in psychiatry as well.

• Democracies generally erode gradually rather than collapsing overnight.¹
• Human beings are remarkably poor at recognizing gradual change while living through it.²
• The psychological processes that shape individuals often resemble those that shape societies.³

As a boy, I thought Never Again was about how history ends.

I’ve come to believe it is really about learning to recognize how history begins.

History Doesn’t Feel Like History

One of the unexpected pleasures of getting older is discovering that books change as much as people do. The words remain exactly the same, yet somehow they become entirely different books.

I first read Viktor Frankl’s Man’s Search for Meaning in college. Like most students, I admired its resilience and philosophy. Years later, after medical school, it became a book about survival. Then I read it again after years of listening to patients describe depression, addiction, grief, trauma, divorce, and recovery. This time it became a book about adaptation. Frankl hadn’t changed. I had.

The same thing happened with Primo Levi, Elie Wiesel, and Aleksandr Solzhenitsyn. When I was younger, I focused on the extraordinary events they described. Reading them decades later, I became fascinated by something much quieter. Their books were filled with ordinary people trying to continue ordinary lives while the world around them gradually became anything but ordinary.

That shouldn’t have surprised me.

History has never exempted people from paying bills, raising children, worrying about work, arguing with their spouses, or deciding what to make for dinner. Revolutions still require grocery stores. Dictatorships still contain birthday parties. Even societies coming apart at the seams remain filled with people trying to get through another Tuesday.

History has an unfortunate habit of unfolding while everyone is busy living their lives.

The more memoirs I read, the less satisfied I became with the way history is usually taught. Textbooks compress years into paragraphs and decades into chapters, creating the illusion that everyone recognized the turning points as they occurred. Memoirs tell a different story. They unfold one ordinary day at a time. The people living through those events had no chapter titles announcing that history was about to change direction. They simply woke up each morning and tried to make sense of the world they found themselves in.

That uncertainty felt remarkably familiar.

Patients often tell me, “I don’t know when this started.” A marriage slowly grows distant. Alcohol becomes a nightly routine. Panic attacks quietly redraw the boundaries of someone’s life. Looking back, the pattern seems obvious. Living through it, almost no one recognizes it.

Perhaps that’s why I eventually stopped asking how entire societies could fail to recognize what was happening around them. The better question became why I ever imagined they would.

• Survivors of authoritarian regimes consistently describe adaptation as gradual rather than sudden.⁴
• Hindsight exaggerates our belief that the past was more predictable than it actually was.⁵
• Memoirs often reveal dimensions of history that traditional narratives cannot.⁶

Looking back, I think I misunderstood Never Again. I thought it was asking us to remember history. It may actually be asking us to recognize it before someone gives it a name.

Ordinary People

There was one book I almost dreaded reading again.

When I first picked up Christopher Browning’s Ordinary Men, I expected a study of monsters. Instead, I met truck drivers, dockworkers, salesmen, clerks, fathers, and middle-aged reservists from Hamburg. They were not chosen because they were unusually cruel or fanatically ideological. They were painfully ordinary. Yet, over time, many became willing participants in the murder of tens of thousands of Jews in occupied Poland.

That was far more disturbing than if Browning had described psychopaths.

Psychiatry has taught me that people rarely experience themselves as villains. They explain themselves. They justify themselves. They remember events in ways that allow them to remain decent people in their own eyes. I’ve heard those explanations thousands of times in my office. They are usually sincere. Most of us don’t wake up intending to make bad decisions. We tell ourselves that we had no better choice, that everyone else would have done the same thing, or that tomorrow will somehow make today’s compromise worthwhile.

History suggests we have always done the same.

Reading memoirs from the twentieth century, I was struck less by the dictators than by everyone else. Parents still worried about report cards. Couples still argued about money. Friends still met for dinner. Children still played outside. Daily life retained a stubborn normality even as the boundaries of that normality were quietly shifting. History, it turns out, doesn’t interrupt ordinary life. It disguises itself as ordinary life.

That realization has changed the way I read history and the way I practice psychiatry. I’m much less interested in dividing people into heroes and villains than I once was. Those categories are comforting, but they explain surprisingly little. Human beings are more complicated than that. Under the right circumstances, we are capable of remarkable generosity, astonishing courage, quiet indifference, and extraordinary cruelty. Sometimes all within the same lifetime.

Perhaps that is why Browning’s title has stayed with me for so many years. He didn’t call the book Evil Men. He called it Ordinary Men.

• Christopher Browning demonstrated that many perpetrators of the Holocaust were psychologically ordinary rather than uniquely sadistic.⁷
• Social conformity and obedience profoundly influence human behavior.⁸
• Most people experience themselves as acting reasonably, even when history later reaches a different conclusion.⁹

The Comfort of Certainty

One of the more humbling lessons psychiatry has taught me is how uncomfortable human beings are with uncertainty.

Patients don’t simply come looking for treatment. They come looking for explanations. They want to know why their marriage failed, why their child developed schizophrenia, why panic attacks appeared after years of perfect health, why going to sleep is so frightening, or why they can’t seem to stop drinking. Sometimes medicine provides satisfying answers. Quite often it doesn’t. Human beings are wonderfully complicated, and our brains seem almost incapable of accepting that complicated things sometimes have complicated causes.

When we can’t know we often become convinced. That tendency extends far beyond psychiatry.

Read enough history and you begin noticing that certainty has always been one of the most valuable political commodities ever invented. People are naturally drawn to those who promise simple explanations for complex problems. Economic hardship becomes the fault of one group. Crime becomes the fault of another. Political disagreement becomes evidence of betrayal rather than disagreement. The explanations are emotionally satisfying precisely because they remove uncertainty from the equation.

Psychiatry has made me deeply suspicious of explanations that seem too complete.

The patients who have taught me the most have almost always been the ones who refused to fit neatly into my expectations. Diagnoses changed. Family members revealed information that transformed my understanding of a case. Laboratory results overturned confident assumptions. Every time I thought I had finally learned how predictable people were, another patient reminded me that they weren’t.

History has had much the same effect.

The more I read, the less interested I become in people who claim to understand everything. Historians argue because history is complicated. Scientists argue because reality is complicated. Psychiatrists argue because people are complicated. Curiously, the people who seem most certain are often discussing subjects that are the least certain of all.

Perhaps that is why certainty has come to worry me more than uncertainty. Uncertainty keeps asking questions. Certainty usually believes it has already found the answers.

• Intellectual humility is associated with better judgment and greater openness to new evidence.¹⁰
• People naturally prefer simple explanations to complex ones, even when reality is more nuanced.¹¹
• Confidence and accuracy are only weakly correlated.¹²

Never Again

As I’ve grown older, I’ve found myself thinking more often about those Passover Seders at my grandfather’s house. At the time, I was mostly interested in getting back to my cousins or seeing what dessert might be coming next. The adults seemed to inhabit a different world; one filled with memories and anxieties that belonged to another generation.

Only years later did I realize they weren’t simply talking about the Holocaust. They were trying to remember how ordinary the world had seemed before everything changed. As a boy, I assumed Never Again referred to concentration camps, mass graves, and liberation. Those were certainly the images I carried with me. Psychiatry, history, and a lifetime of reading gradually taught me that those images belong to the final chapter, not the first.

The first chapter is much quieter. It is written in ordinary conversations, ordinary compromises, ordinary fears, and ordinary people trying to make sense of a changing world. It is written by neighbors who slowly become strangers, by institutions that drift almost imperceptibly, and by millions of people who wake each morning believing they are simply living another ordinary day.

That realization has changed what Never Again means to me. It is no longer simply a promise about the future. It is a discipline of attention. It asks us to remain curious when certainty feels easier, to notice gradual change before it becomes ordinary, and to remember that history rarely announces itself while it is being lived.

Perhaps that was the lesson I had been hearing all along without understanding it. The adults at those Seders weren’t trying to make frightened children. They were trying to make attentive adults.

Hope

There is one more thing I understand now that I couldn’t have appreciated as a child.

For Jews of my grandparents’ generation, the creation of the State of Israel was about far more than geopolitics. Whatever one’s views of its governments, policies, or the conflicts that continue to surround it, Israel represented something profoundly psychological. After nearly two thousand years of exile, expulsions, pogroms, and, ultimately, the Holocaust, there was, for the first time in centuries, a place that suggested history might not always end the same way. A place where Jews might no longer remain entirely at the mercy of other nations.

It is no accident that Israel’s national anthem is HaTikva—The Hope. That hope has never depended on believing Israel is perfect. No nation is. It rests on something more enduring: the belief that the future is not condemned to repeat the past. Looking back, I think that was the lesson hidden inside those noisy Passover Seders. The adults weren’t trying to teach us to fear history. They were trying to teach us to remember it without surrendering to it.

When I was a boy, I thought the lesson of the Holocaust was Never Again. I still believe that. But I have come to think that Never Again is only half the lesson. The other half is HaTikva.

Hope.

Notes and Sources

1. Levitsky, Steven, & Ziblatt, Daniel. How Democracies Die. Crown, 2018.

2. Kahneman, Daniel. Thinking, Fast and Slow. Farrar, Straus and Giroux, 2011.

3. Frankl, Viktor E. Man’s Search for Meaning. Beacon Press, 1946/2006.

4. Levi, Primo. If This Is a Man (Survival in Auschwitz). Orion Press, 1959.

5. Wiesel, Elie. Night. Hill and Wang, 1960.

6. Solzhenitsyn, Aleksandr. The Gulag Archipelago. Harper & Row, 1973.

7. Browning, Christopher R. Ordinary Men: Reserve Police Battalion 101 and the Final Solution in Poland. HarperCollins, 1992.

8. Arendt, Hannah. Eichmann in Jerusalem: A Report on the Banality of Evil. Viking Press, 1963.

9. Lifton, Robert Jay. The Nazi Doctors: Medical Killing and the Psychology of Genocide. Basic Books, 1986.

10. Tetlock, Philip E., & Gardner, Dan. Superforecasting: The Art and Science of Prediction. Crown, 2015.

11. Sagan, Carl. The Demon-Haunted World: Science as a Candle in the Dark. Random House, 1995.

12. Ben-Ghiat, Ruth. Strongmen: Mussolini to the Present. W. W. Norton, 2020.

13. Gilbert, Martin. The Holocaust: A History of the Jews of Europe During the Second World War. Henry Holt, 1985.

14. Imber, Naftali Herz. Tikvatenu (”Our Hope”), 1878, the poem on which Israel’s national anthem, HaTikva, is based.

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Then tomorrow quietly arrived.

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Not with a single unforgettable catastrophe, but with thousands of smaller ones. One unusually hot summer became several. One “historic” wildfire season became the new normal. Hurricanes kept breaking records until meteorologists seemed to run out of adjectives, while “once-in-a-century” floods began appearing every few years, as though the calendar itself had become confused. Communities that once discussed the weather as harmless small talk now watched forecasts with the same anxious anticipation people reserve for biopsy results.

Yet the remarkable story isn’t that these things happened. It’s that they stopped feeling remarkable.

If someone had handed us today’s headlines in 1995, we would have assumed civilization was in the middle of a planetary emergency. Vast stretches of North America disappearing beneath smoke from Canadian wildfires. Rivers across Europe shrinking to levels unseen in generations. Temperatures in parts of the Middle East and the American Southwest reaching ranges once thought incompatible with normal outdoor life. Insurance companies abandoning entire neighborhoods because the financial risk had become impossible to calculate.² Each event would have dominated the news for weeks.

Now they’re Tuesday.

That, more than climate change itself, is what fascinates me. I’m less interested in debating whether the climate is changing than in asking why we’ve stopped reacting as though it is. As a psychiatrist, I spend much of my career thinking about adaptation. The first night you sleep near railroad tracks, every passing train jolts you awake. Six months later, your brain has quietly erased the noise. The refrigerator stops humming. Your new glasses stop feeling strange. The smell from the paper mill vanishes. Our brains are constantly editing out what has become familiar so we can notice whatever is new.

Most of the time, that’s a remarkable gift. Without it, we’d be overwhelmed by every sensation, every minute of every day. But evolution never promised we’d adapt only to good things. We adapt to chronic pain, to political dysfunction, to homelessness on street corners, to school shootings, and it turns out, to living through the largest environmental transformation in the history of human civilization. The very ability that allows us to survive difficult circumstances may also prevent us from recognizing just how extraordinary those circumstances have become.

• Increase in global average temperature since the late 19th century: approximately 1.3–1.5°C.³
• Number of the ten warmest years on record that have occurred since 2014: 10.⁴
• Number of U.S. billion-dollar weather and climate disasters in 1980: 3. In recent years: often more than 25 annually.⁵

Our Brains Weren’t Built for Slow Disasters

Imagine you step outside and see a lion walking across your front lawn. Your heart rate spikes, stress hormones flood your bloodstream, and every ounce of your attention locks onto one question: How do I not become lunch? Evolution rewarded brains that reacted instantly to immediate danger because those were the brains that survived long enough to have children. The people who paused to debate whether the lion represented a genuine threat rarely contributed much to the gene pool.

Climate change doesn’t work that way.

It behaves less like a lion and more like hypertension. Or high cholesterol. Or lead slowly accumulating in a child’s bloodstream. Or cigarettes. The danger isn’t found in any single day but in the accumulation of thousands of days that seem almost identical. One hot summer doesn’t transform a planet. Neither do two. But year after year, almost imperceptibly, the baseline shifts until what once seemed extraordinary begins to feel routine.

This isn’t a flaw in human intelligence; it’s simply how our brains evolved. Psychologists call it hedonic adaptation or habituation, the remarkable ability to stop noticing what has become familiar. Neuroscientists describe something similar through predictive coding, in which the brain gradually ignores expected information so it can devote its limited attention to whatever is novel.⁶ The system works brilliantly most of the time. If we consciously noticed every sound, smell, or sensation every waking moment, we’d never get anything done.

Unfortunately, the same machinery that allows us to ignore the hum of the refrigerator also allows us to ignore slow-moving catastrophes.

As physicians, we encounter this every day. High blood pressure is called the “silent killer” because people usually don’t feel it. Type 2 diabetes often develops over years before anyone realizes something is wrong. Smoking rarely causes lung cancer after the first cigarette, and obesity develops one meal at a time rather than overnight. Much of medicine consists of convincing patients to take seriously conditions that don’t yet feel serious.

Public health has always shared that challenge. Its greatest victories are often invisible because they prevent disasters before anyone notices them. Vaccination programs, clean drinking water, sewage treatment, lead removal from gasoline, food safety regulations, seat belts, tobacco control, and fluoridated water all asked people to care about threats that weren’t immediately obvious.⁷ Climate change belongs squarely in that tradition. It isn’t simply an environmental problem waiting for ecologists to solve. It’s another slow-moving public-health emergency that asks us to care about tomorrow before tomorrow arrives.

• Average time it takes many smokers to develop smoking-related lung cancer: often decades.⁸
• Percentage of U.S. adults with hypertension who have no symptoms attributable to their elevated blood pressure: the vast majority.⁹
• Number of years between recognition of the dangers of lead exposure and the removal of lead from gasoline in the United States: roughly 50.¹⁰

Perhaps that’s why climate change feels so psychologically elusive. It doesn’t demand our attention the way an earthquake or a terrorist attack does. Instead, it quietly rearranges the background of everyday life until yesterday’s record becomes today’s expectation and today’s expectation becomes tomorrow’s normal.

By the time we notice how much the world has changed, we’ve often forgotten what it used to feel like.

When Everything Is Breaking News, Nothing Is

My father subscribed to the morning newspaper and the evening newspaper. Walter Cronkite came on once each night, calmly informed America what had happened, and then politely got out of the way so everyone could watch MASH. There was enough time between crises to actually think about them.

Today we consume more information before breakfast than previous generations encountered in weeks. Our phones vibrate with breaking news before the previous breaking news has finished breaking. Somewhere a celebrity is getting divorced, a politician is outraged, a billionaire is tweeting, a market is crashing, and someone on social media has discovered a new reason civilization is ending by Thursday.

Attention has become one of the world’s most valuable commodities.

Climate change never stopped happening. It simply had to compete.

Every wildfire now arrives just as the next political scandal erupts. Every hurricane is followed by another Supreme Court decision, another war, another economic report, another viral video of someone attempting to microwave aluminum foil. The climate didn’t become less important. It became one more contestant in an endless competition for our limited attention.

Psychologists have long understood that repeated exposure gradually dulls emotional responses.¹¹ News organizations know this too, although they have little choice but to keep feeding the machine. Every headline must be louder than yesterday’s because yesterday’s headline has already disappeared beneath a thousand newer ones. Ironically, the harder everyone works to capture our attention, the less attention any one story receives.

The result is a strange kind of emotional inflation. Record-breaking temperatures no longer feel record-breaking because there was another record last month. A “historic” wildfire barely has time to become history before another one begins. The language itself loses its meaning. If every disaster is unprecedented, eventually unprecedented starts sounding routine.

Bill Hicks joked that, “Watching television is like taking black spray paint to your third eye.”¹² It was a comedian’s exaggeration, but like many good jokes it contained an uncomfortable truth. Constant stimulation doesn’t necessarily make us more informed. Sometimes it simply makes us numb.

This isn’t unique to climate change. We see the same phenomenon after mass shootings. The first dominates the national conversation for weeks. The tenth receives a day. By the hundredth, many Americans struggle to remember where it happened. The events haven’t become less tragic. We’ve simply exhausted our capacity for surprise.

Climate change suffers from the same psychological trap. The emergency continues, but our emotional response gradually fades. Not because the evidence became weaker, but because familiarity quietly replaced astonishment.

• Average American media consumption: well over 10 hours of media exposure per day across platforms.¹³
• Number of weather and climate disasters causing more than $1 billion in damage in the U.S. has increased dramatically over the past four decades.¹⁴
• Human attention span has not increased despite the explosion in available information: still about the same brain, facing exponentially more input.¹⁵

Perhaps the greatest irony is that information has never been more abundant, yet sustained attention has rarely been more scarce. We aren’t ignoring climate change because we know too little. We’re ignoring it because we’re being asked to notice everything else at the same time.

When Facts Become Team Sports

One of the stranger developments of the past few decades is that we’ve managed to turn the weather into a political opinion.

That shouldn’t even make sense. Hurricanes don’t register to vote. Mosquitoes don’t watch cable news. Carbon dioxide has never asked whether you prefer Republicans, Democrats, libertarians, or the Green Party. Nature has always displayed a stubborn indifference to our political identities. Yet somewhere along the way, a scientific question slowly transformed into a cultural one, and once that happened, changing your mind became far more difficult.

Psychologists have known for decades that people rarely form beliefs by carefully weighing evidence and then reaching an objective conclusion. More often, we reach a conclusion first and then spend the next several years hiring our intelligence to defend it.¹⁶ The smarter we are, the better we become at constructing arguments for positions we’ve already adopted. Intelligence, unfortunately, is no vaccine against motivated reasoning. Sometimes it’s simply a more sophisticated lawyer.

I’ve written before that certainty is one of the most intoxicating feelings human beings experience. It feels safe. It feels comforting. Most importantly, it feels like knowledge. But certainty often has very little to do with how much we actually know. Once an issue becomes woven into our identity, evidence is forced to compete with something much stronger: the fear of belonging to the wrong tribe.

Climate change wandered directly into that trap.

Instead of asking, What does the evidence show? we increasingly asked, Who’s saying it? If “our side” believed something, we leaned toward believing it too. If the other side embraced it, skepticism suddenly felt like loyalty. The scientific method quietly gave way to the social method.

Physicians see versions of this every day. Patients arrive convinced that vaccines are dangerous, antidepressants are addictive, gluten is poisoning them, or supplements sold on the Internet can cure diseases that have resisted decades of scientific research. Presenting more evidence often changes surprisingly few minds because facts aren’t really competing against ignorance. They’re competing against identity, community, and the comfort of certainty.¹⁷

Climate change followed the same path. What began as a discussion about atmospheric chemistry gradually became a test of political belonging. Once that happened, each new study, each new hurricane, each new wildfire, and each new temperature record was filtered through a question that had nothing to do with science: Which side benefits if I believe this?

That’s an extraordinarily difficult obstacle to overcome because our brains are social before they’re rational. For most of human history, being expelled from your tribe could be fatal. Evolution cared far more about whether you stayed with your group than whether you happened to be correct about the weather.

The tragedy is that physics doesn’t negotiate. The atmosphere doesn’t compromise. Greenhouse gases don’t care how we voted. Reality has never been particularly interested in our opinions.

• Percentage of Americans who say climate change is happening varies substantially by political affiliation.¹⁸
• People with greater scientific literacy are not necessarily less susceptible to motivated reasoning when issues become politically polarized.¹⁹
• Strong group identity often predicts beliefs more accurately than exposure to factual information alone.²⁰

Perhaps the most effective strategy for delaying action on climate change was never convincing people that it wasn’t real. It was convincing them that accepting the evidence meant joining the other team. Once facts become jerseys, everyone forgets they’re still playing on the same field.

The Patient Is the Environment

When most people hear the phrase climate change, they picture melting glaciers, disappearing forests, rising oceans, or perhaps a lonely polar bear searching for solid ice. They think of it as an environmental issue, something to be debated by climatologists, environmentalists, and politicians.

I don’t.

I see patients.

One of the advantages of practicing medicine is that ideology eventually gives way to physiology. Nobody argues with dehydration. Heat stroke doesn’t care about your voting record. Asthma doesn’t ask whether wildfire smoke came from a red state or a blue state. Every day in medicine reminds us that nature has never been particularly interested in our opinions.

A child comes into the office wheezing because weeks of wildfire smoke have pushed her asthma beyond what an inhaler can control. An older man collapses during a heat wave because medications that normally protect his heart also make it harder for his body to regulate temperature. Someone with chronic kidney disease arrives dehydrated after several days of extreme heat. A family loses its home to flooding, and months later they’re sitting in a psychiatrist’s office wondering why they can’t sleep, why every heavy rain makes their heart pound, and why they suddenly feel unsafe in a place that used to feel like home.

None of them scheduled an appointment because of climate change. They came because climate change had quietly arrived before they did.

That’s the way public health usually works. Physicians spend surprisingly little time treating root causes. We treat their consequences. Cholera isn’t really about diarrhea; it’s about contaminated water. Lung cancer isn’t really about tumors; it’s about tobacco. Lead poisoning isn’t fundamentally about damaged brains; it’s about the environments children inhabit. Long before patients appear in our offices, public health has been asking a different question: What happened upstream?

Climate change belongs squarely in that tradition.

Longer and more intense heat waves increase dehydration, kidney injury, heat stroke, and cardiovascular disease, particularly among older adults, young children, outdoor workers, and people taking medications that interfere with temperature regulation.²¹ Warmer temperatures lengthen pollen seasons, making asthma and allergies more severe, while expanding the habitat of ticks and mosquitoes allows diseases to appear in places where physicians rarely worried about them before.²² Crop failures, drought, flooding, and extreme weather disrupt food supplies, displace families, and create ripple effects that spread far beyond agriculture.

The psychiatric consequences are no less striking. Following hurricanes, floods, wildfires, and prolonged droughts, rates of depression, anxiety, substance use disorders, and post-traumatic stress disorder consistently rise.²³ Even without dramatic disasters, prolonged heat has been associated with greater irritability, aggression, emergency psychiatric visits, and an increased risk of suicide.²⁴ We sometimes joke that people “lose their minds” when it’s hot outside, but the brain is an organ like any other. It requires oxygen, blood flow, sleep, and a relatively stable environment to function well. When the environment changes, so does the brain.

• Heat is the leading weather-related cause of death in the United States.²⁵
• Allergy seasons across much of North America are now weeks longer than they were several decades ago.²⁶
• Climate-related disasters displace millions of people every year, increasing the risk of both physical illness and mental health disorders.²⁷

This is why I’ve become increasingly uncomfortable calling climate change an environmental issue. Of course it is. But it’s also a medical issue, an agricultural issue, an economic issue, a military issue, a national security issue, and certainly a psychiatry issue. Fundamentally, though, it’s a public-health issue because public health has never been about treating disease one patient at a time. It’s about creating the conditions that allow millions of people to remain healthy before they ever need a doctor.

I’ve often written that the patient is the environment. The longer I practice medicine, the less that feels like a metaphor.

The Greatest Trick Climate Change Ever Pulled

There is an old saying, popularized by Charles Baudelaire and later made famous by the film The Usual Suspects, that “the greatest trick the Devil ever pulled was convincing the world he didn’t exist.” It’s a wonderful line because it captures the power of deception. But the more I’ve thought about climate change, the more I’ve come to believe it accomplished something even more remarkable. It didn’t convince us it wasn’t happening. It convinced us that living inside it was normal.

That isn’t the same thing.

Most Americans no longer deny that the climate is changing.²⁸ The debate has quietly shifted from whether it’s happening to what it means, how serious it is, and whether anything can realistically be done. In some ways that’s progress. In another, it reveals something deeply human. We have an extraordinary ability to adapt, even to circumstances that would have seemed unimaginable only a generation ago.

Imagine walking into a high school classroom in 1985 and announcing that, within forty years, parts of the United States would regularly experience temperatures above 120 degrees, wildfire smoke from Canada would turn the skies over New York City orange, billion-dollar weather disasters would become almost routine, insurance companies would begin abandoning entire neighborhoods because the risks had become too expensive to insure, and each year would seem determined to become the hottest ever measured. Nobody would have asked whether climate change was real. They would have assumed civilization itself had entered some kind of prolonged emergency.

Then imagine telling them that, after a while, people would mostly shrug. That may be the strangest part of this entire story.

Human beings are extraordinarily resilient. We have to be. If every tragedy retained its original emotional force forever, grief would never soften, fear would never fade, and none of us could continue living after profound loss. The same remarkable brain that learns to ignore the refrigerator humming in the kitchen, the train passing in the middle of the night, or the smell of the paper mill down the road also learns to ignore summers that are hotter than any in recorded history. What begins as astonishing gradually becomes familiar, and familiarity has an extraordinary ability to disguise danger.

As a psychiatrist, I spend much of my career helping people distinguish between real threats and imagined ones. Anxiety disorders convince people they are living in emergencies that don’t actually exist. Climate change presents the opposite problem. The emergency is real, but our emotional response slowly fades until the danger begins to feel like part of the landscape rather than something demanding our attention. The crisis hasn’t become smaller. Our capacity to be surprised has.

• Average atmospheric carbon dioxide concentration today: more than 425 parts per million, the highest level in millions of years.²⁹
• The last decade has been the warmest ever recorded globally.³⁰
• One of the most consistent findings in psychology is that people adapt emotionally to repeated experiences, even extraordinarily significant ones.³¹

Perhaps that’s the real lesson here. Climate change isn’t only transforming the planet; it’s revealing something profound about ourselves. The same adaptation that allows us to survive hardship can also prevent us from recognizing when hardship has quietly become the new normal. We didn’t stop talking about climate change because it became less important. We stopped talking about it because our brains did what human brains have always done.

They got used to it. And that may be the most dangerous adaptation of all.

Notes and Sources

1. George Carlin. Complaints and Grievances. HBO, 2001.

2. Recent examples include the 2023 Canadian wildfire smoke affecting much of North America, repeated catastrophic flooding in the United States and Europe, prolonged droughts, and insurance companies reducing or withdrawing coverage from high-risk regions.

3. Intergovernmental Panel on Climate Change. Climate Change 2023: Synthesis Report. Sixth Assessment Report (AR6), 2023.

4. World Meteorological Organization. State of the Global Climate reports, 2023–2025.

5. National Oceanic and Atmospheric Administration. Billion-Dollar Weather and Climate Disasters Database.

6. Friston K. “The free-energy principle: a unified brain theory?” Nature Reviews Neuroscience. 2010;11:127-138. See also literature on predictive coding and habituation.

7. Centers for Disease Control and Prevention. Ten Great Public Health Achievements — United States, 1900–1999.

8. American Cancer Society. Health Risks of Smoking Tobacco.

9. American Heart Association. Hypertension (”the silent killer”) educational materials.

10. United States Environmental Protection Agency. History of Leaded Gasoline and Lead Phase-Out.

11. Thompson RF, Spencer WA. “Habituation: A Model Phenomenon for the Study of Neuronal Substrates of Behavior.” Psychological Review. 1966.

12. Bill Hicks. Relentless. 1992.

13. Nielsen. Annual media consumption reports.

14. National Oceanic and Atmospheric Administration. Billion-Dollar Weather and Climate Disasters Database.

15. Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux; 2011. See also cognitive psychology literature on attentional limitations.

16. Ziva Kunda. “The Case for Motivated Reasoning.” Psychological Bulletin. 1990.

17. Stephan Lewandowsky, Ecker UKH, Cook J. Research on misinformation, belief perseverance, and science denial.

18. Pew Research Center. Public opinion surveys on climate change. See also Yale Program on Climate Change Communication.

19. Dan M. Kahan. Research on cultural cognition and identity-protective reasoning.

20. Henri Tajfel and John Turner. Social Identity Theory.

21. Centers for Disease Control and Prevention; World Health Organization. Climate change, heat-related illness, cardiovascular disease, and kidney injury guidance.

22. Centers for Disease Control and Prevention. Climate Change and Health; vector-borne disease and pollen season resources.

23. American Psychiatric Association; World Health Organization. Climate change and mental health reports.

24. Burke M, González F, Baylis P, et al. “Higher temperatures increase suicide rates in the United States and Mexico.” Nature Climate Change. 2018. See also studies on heat and psychiatric emergencies.

25. National Weather Service; Centers for Disease Control and Prevention. Heat-related mortality statistics.

26. National Oceanic and Atmospheric Administration. Climate and pollen season research.

27. Internal Displacement Monitoring Centre. Global Report on Internal Displacement.

28. Yale Program on Climate Change Communication; Pew Research Center. National surveys on climate attitudes.

29. National Oceanic and Atmospheric Administration. Global Monitoring Laboratory; atmospheric carbon dioxide observations.

30. World Meteorological Organization. State of the Global Climate reports.

31. Brickman P, Campbell DT. “Hedonic Relativism and Planning the Good Society.” In: Adaptation-Level Theory. 1971. See also Diener E, Lucas RE, Scollon CN. “Beyond the Hedonic Treadmill.” American Psychologist. 2006.

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The Perfect Roast Chicken

One of the most valuable lessons I’ve ever learned came from a chef, not a psychiatrist.Years ago, when I was a student at the Culinary Institute of America in Hyde Park, I arrived expecting culinary magic. I imagined endless French sauces, impossible pastries, and chefs balancing tiny edible flowers on towers of food with tweezers while speaking rapid-fire French. I assumed greatness meant complexity. Surely the world’s finest chefs were the ones who knew the most techniques, owned the most expensive knives, and could dirty every pan in the kitchen before lunch.

Instead, one of my instructors quietly dismantled that fantasy.

He told us that the mark of a truly accomplished chef wasn’t preparing the most complicated meal imaginable. It was roasting a chicken perfectly. Every single time. The same went for mushroom soup, mashed potatoes, or green beans. Simple food leaves nowhere to hide. If your roast chicken is dry, no amount of truffle oil, edible gold leaf, smoked rosemary, or interpretive parsley placement is going to save you.¹

At the time, I thought it was a strangely anticlimactic lesson. Here I was at one of the world’s premier culinary schools, and my instructor was basically telling me not to screw up dinner.

Only years later did I begin to understand what he meant.

Like a lot of people, I enjoy watching cooking competitions. The contestants on Chopped are astonishingly talented, and I have no doubt that most of them could cook circles around me. Yet over the years I found myself noticing that every season seemed to demand a little more than the one before it. The mystery baskets became stranger. The ingredients became more exotic. The presentations became increasingly theatrical. Every entrée arrived accompanied by a personal story compelling enough to justify its own streaming series. Television, of course, rewards spectacle, and I certainly don’t blame the producers. Four chefs quietly preparing beautiful roast chickens would probably make excellent cooking and terrible ratings. Still, I couldn’t shake the feeling that something subtle had changed. Were we rewarding better cooking, or had we gradually begun rewarding complication itself?

• A perfectly roasted chicken rarely goes viral.
• Liquid nitrogen almost always does.
• There is still no known substitute for getting the basics right.

For a long time, I assumed this was simply how television evolved. Audiences become accustomed to yesterday’s surprises, so producers naturally search for bigger ones tomorrow. Then I started noticing the same pattern outside the kitchen. Patients described jobs demanding ever greater productivity while somehow leaving everyone feeling busier and less accomplished. Smartphones accumulated cameras, sensors, and features that no one realized they needed until the next product launch. Pickup trucks became so enormous they barely fit into suburban garages. Restaurant portions quietly expanded until an entrée designed for one person could comfortably feed two. Every new product promised to be “revolutionary.” Every election became “the most important of our lifetime.” Every political victory was “the greatest,” “historic,” or “the likes of which have never been seen before.” The details differed, but the direction never seemed to change. Bigger. Faster. Stronger. Louder. More.

The strange thing was that I spend much of my professional life rooting for optimization. One of my patients develops increasingly efficient actuators at the University of Colorado. Another, an organic chemist, once told me about an advisor who devoted nearly twenty years to discovering a less expensive way to manufacture ethylene, reducing waste while lowering costs across an enormous industry. Medicine itself is one long exercise in optimization. We search for safer operations, more effective medications, fewer side effects, and better outcomes because those improvements genuinely make people’s lives better. Civilization advances because people keep discovering better ways to solve difficult problems.²

It slowly dawned on me that optimization wasn’t the problem at all.

The problem was forgetting to ask what we were optimizing.

Businesses optimize for profits. Engineers optimize for efficiency. Politicians often optimize for attention. Social media companies optimize for engagement. Physicians optimize for health. Evolution optimized us to survive long enough to reproduce, not necessarily to be happy. Every system optimizes for something, but those goals are not always the same, and they are not always compatible. Looking back, I don’t think my instructor was simply teaching us how to roast a chicken. I think he was teaching us that excellence and excess are not synonyms.

• Markets optimize for demand.
• Public health optimizes for outcomes.
• Evolution optimizes for survival.
• Human flourishing may be an entirely different project.

Perhaps that’s why I’ve always loved something Jerry Garcia once said about the Grateful Dead: “We’re like licorice. Not everybody likes licorice, but the people who like licorice really like licorice.”³ It’s one of the most quietly confident observations I’ve ever heard. Garcia wasn’t trying to become everything to everyone. He wasn’t chasing the largest audience, the highest ratings, or the broadest appeal. He understood that excellence sometimes comes from becoming the best version of yourself rather than the biggest version of yourself.

The older I get, the more I think my cooking instructor and Jerry Garcia were talking about exactly the same thing. Somewhere along the way, we stopped asking how to become better and started assuming the answer was simply more. I have a feeling those are very different questions.

The Attention Economy

Once I started looking for this pattern, I couldn’t stop seeing it. It was tempting to blame social media, politicians, corporations, or television producers, but that explanation never felt quite right. They all seemed to be playing the same game, responding to the same incentives, and if everyone keeps making similar decisions, it’s usually because the rules reward those decisions. Nobody had to call a meeting and decide that everything should become bigger, louder, faster, or more dramatic. Markets simply have a way of nudging people in the same direction until yesterday’s extravagance quietly becomes today’s baseline.

One of the first people to understand this wasn’t a marketer or politician. It was the economist and psychologist Herbert Simon, who wrote in 1971 that “a wealth of information creates a poverty of attention.”¹ At the time, there were no smartphones, no streaming services, no social media influencers filming themselves eating breakfast for millions of strangers. Yet Simon recognized that information was becoming abundant while attention remained finite. If everyone wanted a piece of that limited attention, then attention itself would become one of the world’s most valuable commodities.

Once I read Simon, a great deal of modern life suddenly made more sense. Imagine opening a restaurant where the place across the street advertises “The Best Burger in Boulder.” Calling yours “Pretty Good” probably isn’t much of a business strategy. Before long your sign reads “The Ultimate Burger.” Then someone else offers “The Biggest Burger in Colorado.” Eventually everyone is speaking in superlatives, not necessarily because anyone is lying, but because understatement slowly disappears from a competitive marketplace. Every participant behaves rationally. Collectively, however, they create something that none of them intended.

• Americans encounter thousands of advertisements each day.²
• Human attention has not increased to keep pace.
• Hyperbole has experienced inflation.

The same thing happens to language. Every new smartphone is “revolutionary.” Every streaming series is “the event of the year.” Every weather system is “historic.” Every election becomes “the most important of our lifetime.” Politicians have become especially fluent in this dialect. Donald Trump, for example, rarely describes anything as merely good. It is “the greatest,” “the biggest,” or “the likes of which have never been seen before.” Love him or hate him, he understands the marketplace in which he competes. In a culture saturated with information, ordinary statements are almost invisible. Hyperbole doesn’t simply attract attention. It survives.

This isn’t unique to politics. Walk through any airport bookstore and count how many covers promise life-changing secrets, revolutionary discoveries, or habits that will transform your future. Scroll through social media and every productivity app claims to optimize your life, every supplement promises peak performance, and every podcast advertises conversations you “can’t afford to miss.” The language itself begins behaving like an auction in which everyone keeps bidding higher because standing still feels indistinguishable from falling behind.

The comedian George Carlin once observed, “If you can fake sincerity, you’ve got it made.”³ Confidence sells. Certainty sells. Conviction sells. Nuance usually doesn’t. “This might help under certain circumstances” is rarely as compelling as “This changes everything.”

• Moderation rarely trends.
• “Limited time only” has become a permanent business model.
• Every election can’t be the most important in history.
• Apparently, they all are.

Psychologists call another part of this process hedonic adaptation.⁴ Human beings become accustomed to improvements remarkably quickly. The first smartphone felt miraculous. The tenth felt expected. Yesterday’s luxury becomes today’s necessity, which means tomorrow’s innovation has to become even more impressive just to produce the same emotional reaction. Before long, every industry finds itself participating in the same competition. More features. More speed. More horsepower. More followers. More outrage. More spectacle.

Nobody intended to create an arms race.

Once the race begins, however, nobody wants to finish last.

When Markets Meet Biology

About forty years ago, I read an article in Harper’s Magazine that has stayed with me ever since. I wish I could remember the author’s name because the central idea has become even more relevant over time. The article described how fast-food chains increasingly expanded into lower-income neighborhoods, places where full-service grocery stores were scarce and inexpensive, calorie-dense food was abundant. Today we often call these communities “food deserts,” although many researchers now point out that the problem isn’t simply the absence of healthy food. It’s the overwhelming presence of inexpensive, heavily marketed, highly processed alternatives.⁵

The more I thought about that article, the more I realized it wasn’t really about hamburgers. It was about optimization.

Imagine you’re the CEO of a fast-food company. Your responsibility isn’t to improve public health. Your responsibility is to build a successful business. You compete on convenience, consistency, taste, and price. If the restaurant across the street offers a thousand calories for five dollars, there is enormous pressure to offer eleven hundred calories for the same price. If your competitor invents a larger soda, you introduce one that’s even larger. Nobody has to wake up in the morning thinking, “How can I make America fatter?” They simply ask, “How can I persuade more people to choose my restaurant instead of someone else’s?”

Individually, those decisions are rational. Collectively, they become something else entirely.

• The cheapest calories are often the most processed.
• Portion sizes grew long before our stomachs did.
• Markets reward value. Biology keeps the receipts.

One of the great lessons of public health is that populations rarely become unhealthy because millions of people simultaneously decide to make terrible choices. More often, the environment quietly changes what counts as a reasonable choice. If fresh produce is expensive while highly processed food is inexpensive, if one meal contains twice as many calories for the same price, if every competitor increases portion sizes, then yesterday’s excess gradually becomes today’s normal. Nobody notices the shift because it happens one french fry at a time.

This is one of the reasons obesity has never made much sense to explain as a simple failure of willpower. Human beings evolved during hundreds of thousands of years when calories were difficult to obtain. Under those conditions, finding calorie-dense food was an extraordinary advantage. Our ancestors who eagerly consumed those calories were more likely to survive periods of famine than those who casually pushed away dinner. Evolution did exactly what it was supposed to do.

Unfortunately, evolution has terrible timing.

It prepared us for a world that barely exists anymore.

• Evolution optimizes for survival.
• Businesses optimize for profit.
• Public health optimizes for outcomes.
• Those goals occasionally overlap.
• They often don’t.

Once I began thinking this way, I found myself becoming less interested in assigning blame and more interested in understanding incentives. Businesses generally do exactly what we ask them to do. They compete. They innovate. They optimize. The difficulty arises when one system optimizes for quarterly earnings while another, namely the human body, continues operating under rules written during the Ice Age. Neither system is malfunctioning. They’re simply solving different problems.

That distinction turns out to matter far beyond hamburgers.

Too Much of a Good Thing

Living in Colorado has given me a front-row seat to another remarkable experiment in optimization. Long before legalization, marijuana was generally discussed as though it were a single, relatively stable product. In reality, it has changed dramatically over the past several decades. Through selective breeding, growers steadily increased THC concentrations, applying the same basic principles of genetics that transformed corn, tomatoes, and countless other agricultural products.⁶ Once concentrates became widely available, oils, waxes, shatter, resin, and vape cartridges pushed THC concentrations even higher. From the perspective of the marketplace, the progression was almost inevitable. If consumers enjoyed one level of potency, someone would eventually offer something stronger.

That strategy would have made perfect sense to my patient who designs actuators. Better performance is exactly what engineers are supposed to achieve. It would have made perfect sense to my patient’s advisor who spent two decades developing a more efficient method of manufacturing ethylene. Chemists, engineers, and entrepreneurs all solve problems by making things work better. The difficulty is that human biology doesn’t always define “better” the same way markets do.

One of the strangest consequences has been the growing recognition of Cannabis Hyperemesis Syndrome, a condition characterized by severe, recurrent nausea and vomiting in some heavy cannabis users.⁷ Had someone described this diagnosis to me in medical school, I probably would have assumed they had confused marijuana with another drug. Cannabis was famous for giving people “the munchies.” It was prescribed to help cancer patients tolerate chemotherapy, maintain their appetite, and reduce nausea. The idea that the same substance could eventually produce relentless vomiting sounded almost absurd.

Except biology never promised that more THC would simply amplify the original effects.

Biology almost never works that way.

• The dose matters.
• The duration matters.
• Potency matters.
• Biology always gets the final vote.

Medicine teaches this lesson repeatedly. Antibiotics save lives until they’re overused and resistance develops. Sunlight is essential until it contributes to skin cancer. Exercise improves nearly every aspect of health until injuries replace fitness. Even water, perhaps the most benign substance imaginable, becomes dangerous when consumed in sufficiently large quantities. Physicians spend much of their professional lives searching for what pharmacologists call the therapeutic window, the range where benefits are maximized and harms minimized. We aren’t trying to prescribe the largest dose. We’re trying to prescribe the right dose.⁸

The same principle quietly governs almost every biological system. Too little sleep is harmful, but sleeping fourteen hours every day isn’t generally a recipe for flourishing. Stress sharpens performance until it becomes chronic. Confidence attracts people until it hardens into arrogance. Evolution rarely rewards extremes. More often, it rewards balance.

That is why optimization becomes so fascinating. Engineers naturally search for maximum efficiency because machines generally tolerate being pushed toward their physical limits. Human beings are different. We are not machines. Our brains, immune systems, cardiovascular systems, and digestive systems are built around tradeoffs, feedback loops, and diminishing returns. Push almost any biological system too far in either direction, or eventually it pushes back.

• Maximum is an engineering word.
• Optimum is a biological word.
• Confusing the two has become surprisingly expensive.

The more I considered it, the more I realized this wasn’t really an article about food or cannabis.

It was becoming an article about us.

Optimizing Ourselves

It would be comforting if optimization stopped at fast food, smartphones, or cannabis dispensaries. It doesn’t. Eventually, the same logic finds its way into the mirror.

Not long ago, I came across the relatively new term looksmaxxing, an online movement devoted largely to helping young men become as physically attractive as possible. Skin-care routines, orthodontics, weight training, hair transplants, jawline exercises, fashion advice, supplements, cosmetic procedures, even detailed discussions about facial symmetry have become part of an elaborate strategy for becoming the most desirable version of oneself. At first glance it seems like a distinctly modern phenomenon, but of course it isn’t. Women have been encouraged to optimize their appearance for generations through makeup, dieting, fashion, hair styling, cosmetic surgery, and an endless parade of products promising youth, beauty, and confidence. The internet didn’t invent self-improvement. It industrialized it.⁹

There is nothing inherently wrong with wanting to look your best. There is nothing wrong with exercising, eating well, dressing thoughtfully, or taking pride in your appearance. The problem begins when optimization quietly replaces identity. Somewhere along the way, improving ourselves becomes managing ourselves, and managing ourselves becomes measuring ourselves.

• Sleep score.
• Step count.
• Body fat percentage.
• Resting heart rate.
• VO₂ max.
• Followers.
• Likes.
• Screen time.
• Productivity apps.
• Somehow we’re still exhausted.

As a psychiatrist, I hear echoes of this every day. Patients don’t simply want to sleep better. They want to achieve the perfect sleep score on their smartwatch. They don’t simply want to exercise. They wonder whether they’re exercising enough, taking enough “steps”, eating enough protein, taking the right supplements, tracking the right biomarkers, and optimizing the perfect morning routine they saw online three days ago. Parents worry that one extracurricular activity won’t be enough for college admissions. Then two doesn’t seem like enough. Then three becomes normal. Somewhere between piano lessons, robotics club, travel soccer, volunteer work, debate team, Mandarin tutoring, and summer internships, childhood quietly becomes another optimization project.

The strange thing is that the finish line never seems to move closer.

Psychologists have long recognized that human beings adapt remarkably quickly to improvements. Yesterday’s accomplishment becomes today’s expectation, which becomes tomorrow’s starting point. We buy a larger house, receive a promotion, lose twenty pounds, or achieve another goal, only to discover that satisfaction has an unexpectedly short half-life. The goalposts quietly move again.¹⁰

• Enough is difficult to monetize.
• Dissatisfaction is a renewable resource.
• Self-improvement has become a trillion-dollar industry.

Perhaps that’s inevitable. Companies don’t sell contentment particularly well. They sell possibility. Every advertisement quietly suggests that a slightly better version of yourself is just one purchase away. A new watch. A better mattress. A different diet. Another supplement. Another app. Another course. Another productivity system. Another skin-care routine. Most of those products aren’t fraudulent. Many genuinely help. But taken together they create the unmistakable impression that who you are today is merely the rough draft of who you ought to become tomorrow.

The philosopher Alain de Botton once observed, “There is no such thing as work-life balance. Everything worth fighting for unbalances your life.”¹¹ I suspect something similar is true of optimization. Improvement is healthy. Obsession rarely is. Somewhere between neglecting ourselves and endlessly trying to perfect ourselves lies a quieter place that biology seems to prefer.

• Maximum confidence becomes arrogance.
• Maximum productivity becomes burnout.
• Maximum vigilance becomes anxiety.
• Maximum optimization eventually stops feeling like progress.

The older I get, the less interested I become in maximizing everything. I’m becoming much more interested in finding enough.

Choosing What Matters

One of the unexpected benefits of writing this article has been realizing that optimization itself is neither good nor bad. It’s simply a process. Every engineer, physician, entrepreneur, politician, athlete, scientist, and software designer spends part of their life trying to make something work better. The difficult question isn’t whether we should optimize. The difficult question is what we choose to optimize and what we are willing to sacrifice along the way.

Engineers understand this instinctively. Make an airplane lighter and it becomes more fuel efficient, but only up to a point. Increase an engine’s horsepower and new stresses appear elsewhere in the machine. Every design involves tradeoffs. Good engineers don’t maximize everything. They optimize within constraints. Medicine works exactly the same way. Every treatment has benefits, risks, side effects, costs, and unintended consequences. Physicians aren’t looking for the largest dose or the most aggressive treatment. We’re searching for the point where the patient is most likely to benefit. In other words, we’re searching for the optimum, not the maximum.¹²

The longer I’ve practiced psychiatry, the more convinced I’ve become that mental health follows the same rules. Confidence is healthy until it becomes arrogance. Conscientiousness is admirable until it becomes perfectionism. Vigilance protects us until it turns into anxiety. Ambition builds careers until it crowds out families, friendships, and sleep. Many of the traits we admire are simply virtues that haven’t yet wandered too far from the middle.

• Courage without judgment becomes recklessness.
• Confidence without humility becomes narcissism.
• Efficiency without compassion becomes bureaucracy.
• Optimization without purpose becomes obsession.

The same principle extends far beyond individual psychology. Businesses optimize for quarterly earnings because that’s often how success is measured. Social media platforms optimize for engagement because attention drives advertising revenue. Politicians optimize for votes because elections determine who governs. None of those goals are inherently unreasonable. Problems arise when the metric quietly becomes the mission. If a company measures only profits, profits begin crowding out everything else. If a politician measures only attention, attention eventually becomes more valuable than truth. If social media measures only engagement, outrage becomes remarkably profitable.

As someone with a background in public health, I’ve always been fascinated by the fact that public health asks a fundamentally different question. Businesses naturally ask, “How do we sell more hamburgers?” Public health asks, “What happens if everyone eats them?” Businesses ask how to increase sales of increasingly potent cannabis products. Public health asks what happens when millions of people consume them over decades. Those aren’t opposing questions. They’re simply different optimization problems.

• Markets optimize for demand.
• Public health optimizes for populations.
• Evolution optimizes for survival.
• Human beings still have to decide what kind of society they want to build.

Perhaps that’s why the debates surrounding artificial intelligence have captured my attention so completely. AI engineers are doing exactly what great engineers have always done. They are building systems that are faster, more capable, more efficient, and increasingly powerful. Those are extraordinary achievements. The question isn’t whether they should continue improving these systems. Of course they should. The question is what, exactly, we want those systems to optimize. Speed? Profit? Engagement? Accuracy? Human flourishing? Those objectives overlap sometimes, but not always. Choosing among them may become one of the defining challenges of this century.

When I think back to that instructor at the Culinary Institute of America, I realize he wasn’t telling us to avoid complexity. He wasn’t arguing that innovation was somehow dangerous or that roast chicken represented the pinnacle of civilization. He was reminding us that complexity should serve excellence, not replace it. Adding another ingredient doesn’t necessarily improve a dish. Sometimes it merely makes it harder to notice that the chicken is dry.

The same may be true of modern life.

Choosing Our Objectives

The longer I’ve practiced psychiatry, the more convinced I’ve become that the things people ultimately value are remarkably resistant to optimization. Nobody has ever sat in my office regretting that they failed to answer one more email. No one has wished they had spent more time refreshing social media, accumulated a higher sleep score, or squeezed another productivity app into an already crowded day. Instead, they talk about marriages that drifted apart, children who grew up too quickly, friendships that quietly disappeared, parents they wish they had visited more often, and careers that gradually consumed the parts of life they thought they were working to protect.

Those conversations have made me increasingly suspicious of a culture that treats every problem as though it can be solved by turning another dial a little farther to the right.

• More isn’t the opposite of less.
• More is often the opposite of enough.

Perhaps that’s the real optimization trap. We become so busy maximizing measurable things that we neglect the immeasurable ones. We optimize efficiency while forgetting meaning. We optimize engagement while neglecting attention. We optimize productivity while sacrificing presence. We optimize profits while hoping health somehow takes care of itself. We optimize performance while quietly wondering why so many people feel exhausted.

My instructor at the Culinary Institute wasn’t arguing against ambition. He wasn’t suggesting that chefs should stop learning or that innovation was somehow dangerous. He was teaching something much simpler and much harder. Before you spend your life becoming extraordinarily good at something, make absolutely certain you’ve chosen the right thing to optimize.

That strikes me as good advice for far more than cooking.

One last question before you go:

What do you think we’re optimizing for today that future generations will wonder why we ever valued in the first place?

I’d love to hear your thoughts in the comments.

Notes and Sources

1. Michael Ruhlman. The Making of a Chef. Henry Holt, 1997.

2. Herbert A. Simon. “Designing Organizations for an Information-Rich World.” In Martin Greenberger (ed.), Computers, Communications, and the Public Interest. Johns Hopkins University Press, 1971.

3. Jerry Garcia interviews (various).

4. Daniel Kahneman. Thinking, Fast and Slow. Farrar, Straus and Giroux, 2011.

5. Ed Diener, Richard E. Lucas, and Christie Napa Scollon. “Beyond the Hedonic Treadmill: Revising the Adaptation Theory of Well-Being.” American Psychologist. 2006.

6. Sonja Lyubomirsky. The How of Happiness. Penguin Press, 2008.

7. Robert M. Yerkes and John D. Dodson. “The Relation of Strength of Stimulus to Rapidity of Habit Formation.” Journal of Comparative Neurology and Psychology. 1908.

8. George Carlin. Brain Droppings. Hyperion, 1997.

9. U.S. Department of Agriculture. Food Access Research Atlas.

10. Centers for Disease Control and Prevention. Healthy Food Environments.

11. National Institute on Drug Abuse. Marijuana Research Reports.

12. Allen JH, de Moore GM, Heddle R, Twartz JC. “Cannabinoid Hyperemesis: Cyclical Hyperemesis in Association with Chronic Cannabis Abuse.” Gut. 2004.

13. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 14th Edition.

14. Alain de Botton. The Pleasures and Sorrows of Work. Pantheon, 2009.

15. Barry Schwartz. The Paradox of Choice. Harper Perennial, 2004.

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That may be one of the most memorable things a patient has ever said to me.

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A few weeks earlier, another longtime patient had walked into my office, and I didn’t recognize her. Then it happened again. These weren’t failures of memory. Both women had lost so much weight taking one of the new GLP-1 medications that their faces, posture, and even the way they carried themselves had changed.

One smiled at my confusion.

The other simply said, “I can cross my legs.”

Most of us have done that thousands of times without thinking. For her, it represented freedom. It meant fitting comfortably into a restaurant booth or an airplane seat, moving through the world without constantly negotiating with her own body. Physicians often celebrate improved laboratory values. Patients celebrate moments like these.

For decades, obesity was treated primarily as a failure of willpower. Eat less. Move more. Try harder. The advice wasn’t entirely wrong, but it assumed everyone was fighting the same biological battle. We now know that assumption was incomplete. Medications such as Ozempic, Wegovy, and Mounjaro have forced medicine to reconsider one of its oldest mistakes: confusing biology with character.¹

• Nearly three-quarters of American adults are overweight or obese.²
• Obesity increases the risk of Type 2 diabetes, hypertension, cardiovascular disease, sleep apnea, osteoarthritis, and at least thirteen cancers.³
• Losing just 5-10% of body weight can significantly improve many chronic illnesses.⁴

George Carlin once observed, “Scratch any cynic and you’ll find a disappointed idealist.” Medicine has often been cynical about obesity, assuming people simply weren’t trying hard enough. These medications suggest something far more humbling: many people were fighting biology every single day.

I didn’t realize that until I stopped recognizing my own patients.

A Revolution Hiding in Plain Sight

Medicine doesn’t always change with a dramatic breakthrough. Sometimes a discovery quietly works its way into everyday practice until one day we realize we’re treating patients differently. Antibiotics, insulin, vaccines, and anesthesia all followed that path. GLP-1 medications may someday join that list.⁵

Ironically, they weren’t developed for weight loss. Semaglutide and tirzepatide were designed to treat Type 2 diabetes, but researchers soon noticed that patients were losing remarkable amounts of weight. Even more surprising, many described an unexpected change.

“The food noise is gone.”⁶

Before hearing that phrase from patient after patient, I hadn’t appreciated how many people spend much of their lives negotiating with hunger. They aren’t lacking discipline. Their brains simply keep returning to food. What many notice first isn’t the weight loss. It’s the silence.

As psychiatrists, that immediately catches our attention. Patients with OCD struggle with intrusive thoughts. Patients with anxiety battle relentless worries. “Food noise” may be another example of the brain repeatedly demanding attention; not a character flaw, but a biological process.

• Patients taking semaglutide lose an average of about 15% of their body weight, while tirzepatide approaches 20% or more in many studies.⁷
• Many patients report reduced appetite within the first week of treatment.⁸
• Brain imaging suggests GLP-1 medications influence reward pathways involved in craving and motivation, not simply the stomach.⁹

Steven Wright once joked, “I intend to live forever. So far, so good.”

These medicines don’t just help many people live longer. They help them live with less struggle. And if changing a handful of hormones can quiet hunger so dramatically, perhaps we’ve been asking the wrong question all along. Instead of wondering why some people lack willpower, we should have been asking why some brains generate so much more hunger than others.

The Psychiatric Benefits Nobody Expected

As a psychiatrist, I’m pleased when patients lose weight, improve their blood sugar, or lower their blood pressure. Those are real victories. What has surprised me most, however, is everything that happens afterward.

Patients begin walking because it no longer hurts. They travel without worrying about airplane seats. They stop avoiding family photographs. They play with their grandchildren instead of watching from a chair. They spend less time hiding from life and more time participating in it.

Those aren’t simply physical changes. They’re psychiatric ones. Mental health doesn’t exist in a vacuum. Severe obesity can turn ordinary activities into daily reminders of limitation: climbing stairs, shopping for clothes, fitting into restaurant booths, even crossing a parking lot. Layer enough of those experiences together, and depression, anxiety, and isolation become much easier to understand.¹⁰

Then the cycle begins to reverse.

As sleep apnea improves, people sleep better. As their joints hurt less, they become more active. Activity improves mood, energy, and cardiovascular health, making even more activity possible. A medication that began as a treatment for obesity creates a cascade of psychological benefits.

Psychiatry has recognized this principle for decades. We encourage depressed patients to become more active because experience changes mood. These medications often make that advice realistic for the first time.¹¹

There may also be direct effects on the brain. GLP-1 receptors are widely distributed throughout the central nervous system, and early research suggests these medications may influence inflammation, reward processing, stress, and mood. It’s too early to call them psychiatric medications, but it’s becoming increasingly clear that improving the body often improves the mind.¹²

• Weight loss commonly improves sleep apnea, chronic pain, mobility, insulin resistance, and cardiovascular health.¹³
• Regular physical activity remains one of the most effective non-pharmacologic treatments for mild to moderate depression.¹⁴
• Early studies suggest GLP-1 receptor agonists may influence brain circuits involved in emotion and motivation.¹⁵

Victor Borge once said, “Laughter is the shortest distance between two people.”

Movement isn’t far behind. The more freely people move through the world, the more likely they are to reconnect with friends, family, and, sometimes, themselves. That may be the greatest psychiatric benefit of these medications. They don’t simply help people lose weight.

They help many people get their lives back.

But Weight Isn’t the Whole Story

If this article ended here, these medications would sound like miracle drugs. Psychiatry is rarely that simple. One of our first lessons is that symptoms often serve a purpose. They may be unhealthy, but they solve something. Alcohol quiets anxiety. Gambling creates excitement. Social media relieves boredom. For many people, food does all of the above.

Eating isn’t just about hunger. It’s comfort after a difficult day, celebration with family, ice cream after a breakup, pizza after a stressful week. Food is woven deeply into our emotional lives.

When these medications dramatically reduce appetite, they can also remove one of a person’s oldest coping strategies.

I’ve had patients tell me, “I don’t know what to do with myself anymore.”

They weren’t talking about meals. They were talking about the empty space left behind when food no longer dominated their emotional life. Others discover that what they thought was constant hunger was actually anxiety, loneliness, grief, or boredom. The medication didn’t create those feelings. It simply stopped hiding them.

Psychiatrists see this all the time. Someone stops drinking and discovers depression. Another quits smoking and realizes how anxious they’ve been for years. Removing a coping mechanism doesn’t eliminate the underlying problem. It often reveals it.¹⁶

That’s why I think these medications work best as part of a larger treatment plan, not as a stand-alone cure. Losing a hundred pounds can transform the body. It doesn’t automatically heal trauma, relationship patterns, or decades of emotional habits. Those require different work.

• Emotional eating is strongly associated with depression, anxiety, trauma, and chronic stress.¹⁷
• Many people eat to regulate emotions rather than satisfy hunger.¹⁸
• Major life changes, including weight loss and sobriety, often uncover psychological problems that had been masked by familiar coping strategies.¹⁹

Bill Hicks once joked, “The world is like a ride at an amusement park.”

The same is true of treatment. Solving one problem often reveals the next one waiting in line. That’s not a failure of these medications. From a psychiatrist’s perspective, finally seeing the real problem is often where healing actually begins.

Who Am I Now?

One of the least appreciated consequences of dramatic weight loss has nothing to do with metabolism. It’s identity.

Psychiatrists spend much of our time thinking about how people see themselves, because that internal picture often changes far more slowly than reality. Someone who grew up poor may still worry about every dollar decades later. A veteran may continue scanning every room long after leaving combat. The brain is slow to rewrite its own autobiography.

The same thing happens after major weight loss.

Imagine spending twenty years thinking of yourself as “the overweight one.” You learn which chairs to avoid, buy clothes that hide your body, decline certain activities, and become the funny one before anyone else can make the joke. Then your body changes, but your mind is still reading from the old script.

Patients tell me they still reach for larger clothing sizes, avoid narrow seats, or apologize for taking up space they no longer occupy. Sometimes they’re genuinely startled by the person in the mirror.²⁰. Then other people begin changing, too.

Some patients notice strangers smiling more often. Coworkers become friendlier. They receive compliments from people who barely acknowledged them before. Some begin dating again. Others become unexpectedly angry.

If people treat me differently now, how were they seeing me before?

It’s an uncomfortable question because the evidence is clear: obesity influences hiring, salaries, healthcare, education, and everyday social interactions. We’d like to believe we’re immune to those biases. We’re not.²¹. Weight loss changes more than the person taking the medication. It changes how the world responds to them.

That can reshape relationships. Many become stronger as health improves, but not all. Sometimes a spouse feels threatened, a friend becomes resentful, or long-established family roles begin to shift. When one person changes dramatically, everyone else has to adjust. That’s why I tell patients that major weight loss isn’t simply a medical event. It’s a life event.

Like surviving cancer, achieving sobriety, or becoming a parent, the physical change happens first. The psychological adjustment continues long afterward.²²

• Weight bias affects employment, healthcare, education, and interpersonal relationships.²³
• Many patients continue to experience body-image distortion after substantial weight loss.²⁴
• Psychological adjustment often lags behind physical transformation.²⁵

Ricky Gervais once observed, “We’re all just trying to get through life without looking stupid.”

I’d add that we’re also trying to figure out who we are. Sometimes the hardest part of losing weight isn’t buying smaller clothes. It’s getting acquainted with yourself all over again.

Could These Medications Change Psychiatry?

As remarkable as the weight loss has been, one of the most intriguing discoveries may have little to do with obesity. Researchers began noticing that some patients weren’t simply eating less. They were drinking less alcohol, smoking fewer cigarettes, gambling less, and describing fewer compulsive urges. At first these reports were anecdotal, but they’ve become common enough that formal clinical trials are now exploring whether GLP-1 medications might help treat substance use disorders and other compulsive behaviors.

It’s far too early to draw firm conclusions. Medicine has a long history of exciting observations that failed under careful study. But the possibility is fascinating. Psychiatry has traditionally treated obesity, alcoholism, nicotine dependence, and gambling disorder as separate illnesses. Patients, however, often describe the same underlying experience:

“My brain just keeps telling me to do it again.”

One emerging hypothesis is that GLP-1 medications dampen the brain’s reward circuitry, reducing craving itself rather than targeting a specific addiction. If that proves true, it could reshape how we think about addiction, not as a collection of separate disorders, but as different expressions of a common vulnerability.

We’ve seen this before. Inflammation links diseases once thought unrelated. The immune system influences depression. The gut constantly communicates with the brain. Biology has a habit of ignoring the neat categories in our textbooks.

None of this means GLP-1 medications are ready to become addiction treatments. The evidence remains preliminary, and we should resist outrunning the science. At the same time, we shouldn’t ignore what patients are telling us. Some of medicine’s greatest advances began because clinicians noticed something unexpected and had the curiosity to ask why.

• Early studies suggest some patients taking GLP-1 receptor agonists reduce their alcohol consumption.²⁶
• Clinical trials are evaluating these medications for alcohol, nicotine, and other substance use disorders.²⁷
• Laboratory and neuroimaging studies suggest GLP-1 medications influence reward pathways involved in craving.²⁸

Douglas Adams wrote, “I’ve come up with a set of rules that describe our reactions to technology. Anything invented after you’re thirty-five is against the natural order of things.”

Whether these medications ultimately transform psychiatry remains to be seen. But they’ve already taught us something important: the brain and the body have been having the same conversation all along. We were the ones pretending they spoke different languages.

The Lesson Isn’t About Ozempic

The longer I practice medicine, the less interested I become in explaining human behavior with simple stories about willpower or character. We’ve made that mistake before.

People with depression were told to “snap out of it.” Addiction was dismissed as weak character. Children with ADHD were labeled lazy. Patients with OCD were told to stop worrying. Parents of autistic children were blamed for being emotionally distant. Again and again, science has replaced moral judgment with biology.²⁹

Obesity may be another chapter in that story.

That doesn’t eliminate personal responsibility. These medications aren’t magic, and lasting success still depends on healthier eating, physical activity, and countless daily decisions. But acknowledging biology isn’t the opposite of responsibility. It’s the beginning of effective treatment.

As a psychiatrist, I can’t help wondering how many people spent decades believing they were failures when they were actually fighting a disease medicine didn’t yet understand. How many families unintentionally deepened shame with well-meaning advice? How many physicians mistook the limits of science for the limits of their patients?

Those are uncomfortable questions. They’re also the right ones. Practicing psychiatry teaches humility. Every patient brings an invisible mixture of genetics, childhood experiences, relationships, trauma, resilience, luck, and biology. The more closely we look, the less interested we become in assigning blame and the more interested we become in understanding.

Perhaps that’s the real story of GLP-1 medications. Yes, they lower blood sugar, improve blood pressure, reduce the risk of chronic disease, and help people lose remarkable amounts of weight. But they’ve also challenged one of medicine’s oldest assumptions: that obesity is primarily a failure of willpower.

I keep thinking about my patient who smiled and said,

“I can cross my legs.”

She wasn’t celebrating a number on a scale. She wasn’t talking about BMI, hemoglobin A1c, or clinical trials. She was celebrating a small piece of her life that she’d gotten back. No patient has ever walked into my office asking for a lower A1c or a better lipid panel. They come because they want their lives back. They come because they want to climb stairs without stopping, play with their grandchildren, travel, dance at weddings, and sit comfortably in a restaurant booth.

• More than 100 million American adults live with obesity.³⁰
• Weight stigma remains one of the most common and socially accepted forms of discrimination in healthcare.³¹
• Increasingly, science is teaching us that compassion was the correct response all along.

Carl Sagan wrote, “It pays to keep an open mind, but not so open your brains fall out.”

Medicine asks exactly that of us. Follow the evidence, even when it forces us to abandon old assumptions. If Ozempic, Wegovy, Mounjaro, and the medications that follow teach us anything, I hope it isn’t simply how to help people lose weight.

I hope they teach us to judge a little less, wonder a little more, and remember that every diagnosis belongs to a human being whose battle we may never fully see.

Notes and Sources

1. Ozempic, Wegovy, and Mounjaro are members of a newer class of medications that target the GLP-1 receptor (tirzepatide also activates GIP receptors), improving glycemic control while substantially reducing appetite and body weight.

2. Centers for Disease Control and Prevention. Adult Obesity Facts. Current CDC estimates indicate that nearly three-quarters of U.S. adults are overweight or obese, and more than 100 million meet criteria for obesity.

3. Centers for Disease Control and Prevention. “Overweight & Obesity.” Obesity is associated with Type 2 diabetes, hypertension, cardiovascular disease, obstructive sleep apnea, osteoarthritis, and at least thirteen obesity-associated cancers.

4. American Diabetes Association. Standards of Care in Diabetes—2026. Sustained weight loss of only 5-10% produces clinically meaningful improvements in glycemic control, blood pressure, and cardiovascular risk.

5. Wilding JPH, et al. “Once-Weekly Semaglutide in Adults with Overweight or Obesity.” New England Journal of Medicine. 2021;384:989-1002.

6. Jastreboff AM, et al. “Tirzepatide Once Weekly for the Treatment of Obesity.” New England Journal of Medicine. 2022;387:205-216.

7. Blundell JE, Finlayson G. Appetite control and GLP-1 receptor agonists. International Journal of Obesity. 2024. Many patients describe a dramatic reduction in persistent thoughts about food, often referred to as “food noise.”

8. Decarie-Spain L, et al. GLP-1 receptor signaling and central reward pathways. Nature Reviews Endocrinology. 2024. GLP-1 medications influence neural circuits involved in motivation, reward, and craving, not simply the stomach.

9. Rubino F, et al. Joint International Consensus Statement for Ending Stigma of Obesity. Nature Medicine. 2020;26:485-497.

10. American Heart Association. Obesity and Cardiovascular Disease Scientific Statement. Circulation. 2021.

11. Schuch FB, et al. Physical Activity and Incident Depression. American Journal of Psychiatry. 2018;175:631-648.

12. Hölscher C. GLP-1 receptor agonists in neuropsychiatric disease. Neuropharmacology. 2023.

13. Konttinen H. Emotional Eating and Obesity. Appetite. 2020;151:104695.

14. Marlatt GA, Donovan DM (eds.). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. 2nd ed. Guilford Press; 2005.

15. Puhl RM, Heuer CA. The Stigma of Obesity: A Review and Update. Obesity. 2009;17:941-964.

16. Cash TF. The Body Image Workbook. 2nd ed. New Harbinger Publications; 2008.

17. Klausen MK, et al. GLP-1 receptor agonists and alcohol consumption: A systematic review. Addiction Biology. 2024.

18. National Institute on Drug Abuse. Ongoing clinical trials evaluating GLP-1 receptor agonists in alcohol, nicotine, and other substance use disorders.

19. Insel TR. Healing: Our Path from Mental Illness to Mental Health. Penguin Press; 2022.

20. Kandel ER. In Search of Memory. W.W. Norton; 2006.

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I’ve probably heard that sentence a thousand times.

Sometimes it’s a patient trying to explain years of alcohol, marijuana, cocaine, or opioid use. More often it’s a worried parent describing a son or daughter whose life seems to ricochet from one obsession to another.

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“He gets addicted to everything.”

“She always has.”

“If it wasn’t alcohol, it would’ve been gambling.”

“If he hadn’t found marijuana, it would’ve been something else.”

The phrase has become so common that most people assume it’s an actual psychiatric diagnosis. It sounds scientific, almost reassuring, as though we’ve finally identified the culprit. Case closed.

Except it isn’t.¹

One of my favorite observations by George Carlin was, “Inside every cynical person, there is a disappointed idealist.” I sometimes wonder if the same is true here. Inside every person who says “addictive personality” is someone honestly trying to understand why two people can make the same bad decision while only one loses control of their life.

After all, that’s exactly what we see.

One person drinks socially for forty years and barely thinks about alcohol. Another has a few drinks in college and spends the next twenty years trying to recreate that feeling. One teenager experiments with marijuana a handful of times and moves on. Another quickly graduates to nicotine, cocaine, sports betting, online gambling, or whatever else promises to change the channel inside their own head.

Those differences are real.

The explanation, however, turns out to be far more interesting than most of us were taught. Despite decades of research, psychologists have never found a single personality type that reliably predicts addiction. There is no diagnosis called an “addictive personality,” and there never has been.²

That doesn’t mean my patients are wrong. They’re noticing an unmistakable pattern. The mistake isn’t in the observation. It’s in the explanation.

As Carl Sagan reminded us, “It is far better to grasp the universe as it really is than to persist in delusion, however satisfying and reassuring.”³ Addiction has turned out to be one of those subjects where the truth is messier, more complicated, and ultimately far more hopeful than the myth.

• Americans aged 12 and older with a substance use disorder: about 48 million.⁴
• Estimated heritability of substance use disorders: roughly 40-60%.⁵
• Official psychiatric diagnoses called “Addictive Personality”: zero.

When Psychiatry Changed Its Mind

The idea of an addictive personality didn’t appear out of nowhere. For much of the twentieth century, it seemed perfectly reasonable.

Psychiatrists repeatedly encountered patients who would use almost anything that altered consciousness. If alcohol wasn’t available, there was marijuana. If marijuana wasn’t available, there were stimulants, opioids, benzodiazepines, hallucinogens, inhalants, or whatever happened to be lying around. They didn’t seem particularly loyal to any one drug. They simply wanted to feel...different.

That pattern appeared often enough that it eventually earned its own diagnosis. The DSM-IV included Polysubstance Dependence, describing people who repeatedly used multiple classes of drugs without a clear “drug of choice.”⁶ It seemed to confirm what clinicians already suspected: perhaps some people weren’t addicted to alcohol or cocaine. Perhaps they were addicted to intoxication itself.

It was an elegant theory. Unfortunately, elegant theories have an annoying habit of colliding with data.

Researchers spent decades searching for the personality profile that would explain addiction. They measured impulsivity, anxiety, extroversion, neuroticism, conscientiousness, sensation-seeking, and virtually every other trait psychologists could reliably quantify. If an addictive personality existed, they reasoned, it should eventually reveal itself.

It never did.⁷

Instead, the studies kept finding something far less satisfying. People with addictions looked remarkably different from one another. Some were thrill-seekers. Others were painfully anxious. Some were socially outgoing. Others preferred to be left alone. Some were wildly impulsive, while others balanced their checkbooks to the penny before pouring their fourth bourbon of the evening.

As Steven Wright joked, “It’s a small world, but I wouldn’t want to have to paint it.” Addiction research often feels the same way. The closer scientists looked, the bigger and more complicated the picture became.

By the time the DSM-5 was published in 2013, Polysubstance Dependence quietly disappeared.⁸ Not because those patients had vanished, but because researchers had reached a different conclusion. They weren’t looking at one disorder after all. They were looking at many different disorders that often happened to occur in the same person.

The patients hadn’t changed. Only our understanding of them had.

• Polysubstance Dependence first appeared in the DSM: 1987.⁶
• It disappeared in the DSM-5: 2013.⁸
• Number of validated personality profiles that accurately predict addiction: none.⁷

There Isn’t One Road to Addiction

Once researchers stopped looking for an addictive personality, they found something much more interesting. There wasn’t one explanation for addiction. There were dozens.

Some people inherit brains that respond unusually strongly to rewards. Others grow up in chaotic or traumatic homes and discover that alcohol, opioids, or marijuana can temporarily quiet anxiety, fear, or emotional pain. Some have untreated ADHD and spend years chasing stimulation simply because their brains are chronically under-aroused. Others develop addictions only after surgery, an injury, or long-term exposure to prescription pain medication.⁹

From the outside, these patients often look remarkably similar. They all struggle to stop using a substance that is clearly harming them. Under the surface, however, they may have almost nothing in common.

Twin and adoption studies suggest that roughly 40 to 60 percent of a person’s vulnerability to addiction is inherited.¹⁰ That doesn’t mean there is an “alcohol gene” or a “cocaine gene.” If only biology were considerate enough to make psychiatry that easy.

Instead, inherited differences seem to affect broader traits: how strongly we respond to rewards, how easily we tolerate stress, how quickly we become bored, how impulsively we act, and how effectively we regulate our own behavior. Those traits can increase the risk of many different addictions rather than pointing toward one particular drug.

Life experience matters just as much.

One of the most influential discoveries in modern psychiatry came from the Adverse Childhood Experiences (ACE) studies, which found that the risk of addiction rises steadily as childhood adversity accumulates.¹¹ Abuse, neglect, domestic violence, parental substance use, and chronic household instability don’t create an addictive personality. They change the developing brain. Stress-response systems become more reactive, emotional regulation becomes more difficult, and substances that temporarily relieve distress become far more reinforcing than they might be for someone who grew up in a stable environment.

As Marc Maron once joked, “My brain is like a browser with 37 tabs open.” That’s funny because so many people recognize themselves in it. For some patients, alcohol or drugs aren’t about getting high nearly as much as they’re about finally getting one of those tabs to close.

The deeper researchers looked, the less addiction resembled a personality trait and the more it resembled a meeting place where genetics, development, psychology, and environment all converged. Two people may arrive at the same diagnosis by traveling entirely different roads.

That’s why asking, “Does this person have an addictive personality?” is probably the wrong question. A better question is, “What made this particular person vulnerable?”

The answer is rarely simple. But it is almost always more useful.

• Estimated heritability of substance use disorders: 40-60%.¹⁰
• Adults reporting at least one adverse childhood experience: about 60%.¹¹
• Number of identified genes that reliably predict addiction by themselves: zero.
• Number of roads leading to addiction: far more than one.

Maybe It’s Not Personality. Maybe It’s Self-Regulation.

If there’s one idea that has changed the way I think about addiction over the course of my career, it’s this: perhaps what many people call an addictive personality is actually difficulty regulating behavior.

Consider how often addiction travels with other seemingly unrelated problems. The patient who drinks too much is sometimes the same person who overspends, binge eats, blurts things out in conversations, buys things online they don’t need, drives too fast, procrastinates until the last minute, or enthusiastically begins a new hobby before abandoning it a week later. None of these behaviors are identical, but they all have something in common. They involve choosing an immediate reward despite knowing there may be consequences tomorrow.

Neuroscientists refer to the collection of mental abilities that help us avoid those decisions as executive functions. They allow us to pause before acting, tolerate frustration, delay gratification, organize our thoughts, resist distractions, and keep long-term goals in mind while short-term temptations are screaming for attention. These abilities depend heavily on the prefrontal cortex, one of the last parts of the brain to fully mature.¹²

When those systems aren’t working efficiently, intelligence often isn’t the problem. Neither is knowledge.

Most people with addictions know perfectly well that another drink, another pill, or another bet is a bad idea. Many can list the consequences in painful detail. The difficulty isn’t understanding what they should do. It’s consistently doing it.

Psychiatry offers one particularly interesting window into this process: ADHD. Adults with untreated ADHD frequently struggle not only with attention but also with impulsive decision-making, emotional regulation, delaying gratification, and resisting distractions. It’s therefore not surprising that ADHD is associated with substantially higher rates of substance use disorders.¹³

One of the more fascinating things I’ve seen in practice is that some patients treated successfully for ADHD unexpectedly begin reporting other changes. They drink less. They binge eat less. They stop making impulsive online purchases. Gambling loses some of its appeal. It’s not because stimulant medications directly treat alcoholism or compulsive shopping. Rather, improving executive functioning sometimes allows people to regain control over behaviors that previously felt almost automatic.

As Ricky Gervais once joked, “We’re all basically animals. We’re just the only ones with mortgages.” The joke works because civilization depends largely on one remarkable ability: resisting the urge to do whatever feels good right this second. Addiction, in many ways, represents one of the places where that system begins to break down.

For a while, this seemed like the answer. Perhaps addiction wasn’t a personality disorder after all. Perhaps it was fundamentally a disorder of self-regulation. It was an attractive theory. It just wasn’t the whole story.

• The prefrontal cortex continues developing into the mid-twenties.¹²
• Adults with ADHD have significantly higher rates of substance use disorders than the general population.¹³
• Number of patients who have told me, “I knew it was a bad idea while I was doing it”: approximately all of them.

Then There Are the Accountants

Just when the theory of self-regulation begins to explain addiction beautifully, another group of patients comes along and complicates everything.

Throughout my career, some of the most severe addictions I’ve treated have belonged to people whose lives were otherwise models of discipline. They balanced their checkbooks to the penny, filed their taxes early, rarely broke rules, arrived punctually for every appointment, and built successful careers that depended upon organization, precision, and remarkable self-control. They were engineers, physicians, attorneys, professors, accountants, and business executives. If impaired self-regulation were the entire explanation, these are exactly the people we would expect to be least vulnerable to addiction.

Yet every evening they drank themselves unconscious.

Their addiction wasn’t one symptom of a generally chaotic life. In many cases, it was the only part of their lives that appeared out of control. That contradiction forced researchers to reconsider the idea that addiction could be explained simply by impulsivity or poor self-control. Something else seemed to happen as addiction progressed.

Over the past several decades, addiction neuroscience has increasingly distinguished between impulsivity and compulsivity.¹⁴ Early in an addiction, behavior is often driven by reward. Alcohol is enjoyable. Cocaine produces confidence and energy. Gambling is exciting. Opioids create euphoria. The motivation is largely to experience pleasure.

Years later, however, patients often describe an entirely different experience. Many tell me they no longer enjoy drinking at all. They drink because they cannot sleep without alcohol. Others continue using opioids primarily to avoid withdrawal, or gamble because the temporary relief from anxiety has become more compelling than the money they inevitably lose. Somewhere along the way, the purpose of the addiction quietly changes. The pursuit of pleasure gradually gives way to the avoidance of suffering.

That transition may be one of the defining features of addiction. What begins as an impulsive, reward-seeking behavior slowly evolves into a compulsive attempt to escape distress. Repeated exposure to addictive substances reshapes the neural circuits involved in reward, habit formation, stress, and decision-making.¹⁵ By the time many people finally seek treatment, they are no longer asking how to feel better. They are simply trying to avoid feeling worse.

This is one of the reasons the phrase “addictive personality” has gradually fallen out of favor among addiction researchers. It suggests a fixed character trait when addiction is better understood as a dynamic process. The person who first reached for a drink because it was exciting may bear little resemblance, years later, to the person who reaches for that same drink simply to feel normal again. The addiction has changed because the brain has changed.

• Many addictions begin by pursuing pleasure and eventually become attempts to avoid suffering.¹⁴
• Repeated drug exposure produces measurable changes in brain circuits involved in reward, stress, and habit formation.¹⁵
• Number of patients who have told me, “I don’t even enjoy it anymore”: more than I could possibly count.

So, Is There Such a Thing as an Addictive Personality?

By the time patients arrive in my office, the question has usually shifted. They aren’t asking whether addiction exists. They know that all too well. What they’re trying to understand is why it happened to them and not to someone else. Why could their brother drink socially without much interest, while alcohol quietly took over their own life? Why could a friend stop taking pain medication after surgery while they could not? Why did they seem unable to walk away when other people apparently could?

For years, “addictive personality” seemed like a satisfying answer. It suggested that addiction was simply part of who someone was, a fixed trait that explained everything from alcoholism to gambling to compulsive shopping. It was neat, memorable, and easy to understand.

It also turned out to be wrong.

The more scientists learned about addiction, the less it resembled a personality and the more it resembled a complicated interaction between genetics, brain development, childhood experiences, emotional regulation, stress, learning, and environment. People arrived at addiction by many different roads, and once they got there, the illness itself continued to evolve. The brain that first sought excitement was often very different from the brain that, years later, sought only relief.

That shift in understanding has important consequences. If addiction is viewed as a personality flaw, treatment naturally becomes focused on changing character. If it is understood as a disorder involving learning, reward, memory, stress, executive functioning, and neurobiology, the conversation becomes much more hopeful. We begin asking not, “What’s wrong with this person?” but, “What happened to this person, and how can we help?”

Patients who describe themselves as having an addictive personality are not imagining their struggles. They’re recognizing that something about the way their minds respond to rewards, habits, or emotional distress differs from those around them. What they’re experiencing is real. The phrase they’ve chosen simply doesn’t capture what decades of research have gradually uncovered.

Perhaps the most useful lesson is also the simplest. Labels should help us understand people, not stop us from asking questions. “Addictive personality” closes the conversation just when it becomes most interesting. Understanding addiction means looking beyond the label to the unique combination of biology, psychology, development, and life experience that shaped the person sitting in front of us.

That may not be as tidy an explanation. But it is a far more human one.

• Official psychiatric diagnosis called “Addictive Personality”: none.²
• Number of different pathways known to contribute to addiction: many.⁹
• Number of patients who deserve curiosity before judgment: all of them.

I’d love to hear your thoughts. Have you ever described yourself—or someone else—as having an “addictive personality”? Did this article change the way you think about addiction, even a little?

If you found this worthwhile, please consider subscribing, sharing it with someone who might enjoy it, or leaving a comment. Those small gestures help these essays reach readers who are curious enough to keep asking questions. Even about ideas we thought had already been settled.

Notes and Sources

¹ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022. Substance-Related and Addictive Disorders, pp. 543-621.
² American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). Washington, DC: American Psychiatric Association; 1994. Polysubstance Dependence, pp. 292-294.
³ Carl Sagan. The Demon-Haunted World: Science as a Candle in the Dark. New York: Random House; 1995, p. 36.
⁴ Substance Abuse and Mental Health Services Administration. 2023 National Survey on Drug Use and Health (NSDUH). Adults and adolescents meeting criteria for substance use disorders.
⁵ Kenneth S. Kendler, Carol A. Prescott. Twin studies of substance use disorders. See also Nora D. Volkow and George F. Koob. New England Journal of Medicine. 2016;374:363-371.
⁶ American Psychiatric Association. DSM-III-R. Washington, DC: American Psychiatric Association; 1987. Introduction of Polysubstance Dependence, pp. 172-175.
⁷ Howard J. Shaffer. “The Most Important Unresolved Issue in the Addictions: Conceptual Chaos.” Substance Use & Misuse. 1997;32(11):1573-1580.
⁸ American Psychiatric Association. DSM-5. Washington, DC: American Psychiatric Association; 2013. Elimination of Polysubstance Dependence.
⁹ George F. Koob and Nora D. Volkow. “Neurobiology of Addiction: A Neurocircuitry Analysis.” The Lancet Psychiatry. 2016;3:760-773.
¹⁰ Kenneth S. Kendler et al. “The Structure of Genetic and Environmental Risk Factors for Common Psychiatric and Substance Use Disorders.” Archives of General Psychiatry. 2003;60:929-937.
¹¹ Vincent J. Felitti et al. “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults.” American Journal of Preventive Medicine. 1998;14(4):245-258.
¹² Russell A. Barkley. Executive Functions: What They Are, How They Work, and Why They Evolved. New York: Guilford Press; 2012, pp. 25-67.
¹³ Stephen V. Faraone, Joseph Biederman, and colleagues. Reviews of ADHD and substance use disorders. World Psychiatry and related publications.
¹⁴ George F. Koob and Michel Le Moal. “Drug Addiction, Dysregulation of Reward, and Allostasis.” Neuropsychopharmacology. 2001;24:97-129.
¹⁵ Nora D. Volkow, Ruben D. Baler, and colleagues. “The Neuroscience of Drug Reward and Addiction.” Physiological Reviews. 2017;97:1449-1506.

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Every few weeks another headline announces that boys are struggling. Men are lonelier than they used to be. Fewer are attending college. Many report having no close friends. Suicide rates remain stubbornly high, and increasing numbers of young men seem to be drifting through adulthood without the relationships or sense of purpose previous generations expected. As a psychiatrist, I see these struggles every week. They are real, and they deserve serious attention.¹

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This isn’t an article about winners and losers. It’s about what happens when a society finally begins making fuller use of its own talent.

I hope you enjoy it.

At the very same time, another story has been unfolding.

Over the past century, women have entered nearly every profession, every university, every courtroom, every laboratory, every operating room, every boardroom, and nearly every level of government. A hundred years ago, much of that would have seemed unimaginable. Today, it feels almost ordinary.

That, I think, is the remarkable part.

Most people describe this as a story about women’s rights. It certainly is. But it’s also a story about economics, public health, psychology, and civilization itself. What happens when a society stops excluding half of its own talent? What changes when millions of people who were once expected to remain on the sidelines begin participating fully in building the future?

For thousands of years, civilizations deliberately limited opportunities for roughly half the human population. We usually describe that history as discrimination, and rightly so. But from another perspective, it may also represent one of the least efficient management decisions our species ever made. Imagine a hospital refusing to hire half of all graduating physicians, or NASA deciding that only half of its engineers could calculate whether astronauts returned safely to Earth. No successful organization would voluntarily ignore half of its qualified talent.

Yet that’s essentially what civilizations did.

Women were rarely excluded because they lacked intelligence or creativity. They were excluded because intelligence and creativity weren’t the qualities society had chosen to reward. Looking back, the greatest losses are impossible to measure. We can document the opportunities women were denied, but we can never count the discoveries that were never made, the companies that were never founded, the patients who were never treated, or the books that remained forever unwritten because someone never received the chance.

• Women comprise just over half of the U.S. population.²
• Women now earn nearly 60 percent of bachelor’s degrees in the United States.³
• Women also earn the majority of master’s and doctoral degrees.³
• Civilization spent centuries assuming those last two bullets could never happen.

As Gloria Steinem observed, “The story of women’s struggle for equality belongs to no single feminist nor to any one organization, but to the collective efforts of all who care about human rights.”⁴ That quotation is usually understood as a statement about women. I think it’s equally a statement about civilizations. Healthy societies gradually widen the circle of people allowed to contribute. Unhealthy societies spend their energy explaining why the circle should remain small.

Perhaps we’ve been asking the wrong question all along. Instead of asking what women gained, we should ask what civilization gained.

The answer reaches into almost every corner of modern life. It changed medicine, education, science, business, politics, public health, and the economy. More importantly, it changed what civilization believed was possible. Like every great social experiment, however, it also produced surprises. Some problems became smaller. Others appeared for the first time. Progress has always worked that way.

A Century Is the Blink of an Eye

One of history’s greatest tricks is making recent change feel ancient. Ask someone under thirty whether women should be physicians, judges, fighter pilots, or members of Congress, and the question itself seems absurd. Of course they should. Yet only a century ago, many of those careers were effectively closed to women.

A hundred years sounds like a long time until you realize it’s only about four generations. Many Americans personally knew grandparents born before women could vote. Many women alive today remember needing a husband’s signature to obtain credit, being asked during job interviews whether they intended to have children, or entering professions where they were treated as exceptions rather than colleagues. These aren’t stories from medieval Europe. They’re memories.

The transformation happened with astonishing speed. During the lifetime of a single family, women moved from fighting for admission to universities and professions to leading them. They became department chairs, judges, astronauts, military officers, CEOs, senators, governors, and Nobel Prize winners. Every generation inherited a world that looked noticeably different from the one their mothers entered.

• Women gained the constitutional right to vote in 1920, although many women of color continued to face barriers until the Voting Rights Act of 1965.⁵
• The Equal Pay Act became law in 1963.⁶
• The Civil Rights Act of 1964 prohibited employment discrimination based on sex.⁷
• The Equal Credit Opportunity Act of 1974 allowed women to obtain credit independently.⁸
• Title IX transformed educational opportunities for girls and women.⁹
• Marital rape was not criminalized in every state until 1993.¹⁰

That final date is still startling. Nineteen ninety-three isn’t ancient history. It was the year Jurassic Park filled movie theaters and The X-Files premiered on television. Many physicians, attorneys, professors, and members of Congress practicing today had already begun their careers. History often feels much farther away than it really is.

Most revolutions don’t announce themselves with fireworks. They arrive disguised as ordinary Tuesdays. Someone opens a bank account in her own name. Someone applies to medical school without wondering whether women belong there. Someone argues a case before the Supreme Court. Someone becomes the first female police chief, governor, fighter pilot, or CEO. Then another follows, and another after that, until eventually the adjective quietly disappears. She is no longer the female surgeon or the female engineer. She’s simply the surgeon.

Education illustrates that transformation particularly well. Women once fought simply for admission to universities that now compete to recruit them. Today they earn most bachelor’s, master’s, and doctoral degrees in the United States and comprise roughly half, or more than half, of new physicians, pharmacists, veterinarians, dentists, and attorneys.¹¹

As Ruth Bader Ginsburg observed, “Women belong in all places where decisions are being made.”¹² We usually hear that as an argument about equality. It is equally an argument about competence. Every time a society expands the number of people allowed to solve problems, it improves the chances that those problems will actually be solved.

The rights women gained transformed millions of individual lives. The opportunities civilization gained transformed itself.

The World’s Largest Untapped Resource

Economists spend a great deal of time thinking about resources. Nations become wealthy because they possess fertile farmland, navigable rivers, oil, coal, or valuable minerals. Entire wars have been fought over what lies beneath the ground. Yet for most of history, civilization overlooked what may have been its greatest resource simply because it had become accustomed to overlooking it.

Half the population.

Looking back, it’s astonishing how confidently societies limited their own talent. Imagine a hospital refusing to hire half of all graduating physicians or a university declining to interview half of its applicants before reading a single résumé. Those institutions wouldn’t survive for long. Yet civilizations functioned that way for centuries, not because women lacked ability, but because ability wasn’t what society had chosen to reward.

The remarkable story of the past hundred years isn’t simply that women entered universities, laboratories, hospitals, courtrooms, and businesses. It’s how quickly they demonstrated that the old assumptions had been wrong. Once the barriers fell, women didn’t spend generations proving themselves. They simply began doing the work they had always been capable of doing.

Education offers the clearest example. Women now earn most bachelor’s, master’s, and doctoral degrees in the United States and make up roughly half, or more than half, of new physicians, pharmacists, veterinarians, dentists, and attorneys.¹³ Those statistics are often presented as victories for women, but they’re also evidence that civilization had spent centuries overlooking an extraordinary amount of talent.

• Women receive nearly 60 percent of bachelor’s degrees in the United States.¹⁴
• Women earn the majority of master’s and doctoral degrees.¹⁴
• Nearly half of U.S. medical students are women.¹⁵
• Girls now outperform boys on many educational measures.¹⁶
• It’s remarkably difficult to benefit from talent you’ve already decided not to notice.

The phrase “a man’s profession” has always struck me as peculiar. Physics doesn’t possess a Y chromosome. Neurosurgery isn’t biologically male. Constitutional law doesn’t grow a beard. Those occupations never belonged to men. We simply became accustomed to seeing men perform them and eventually mistook tradition for biology.

Of course, equal opportunity doesn’t require identical outcomes. Human beings differ enormously in personality, interests, ambition, and temperament. Some people dream of designing spacecraft. Others want to teach, write novels, practice medicine, build houses, raise children, or compose music. Equality has never meant everyone should choose the same path. It means people should be free to discover the path that best fits their abilities.

As Jane Goodall observed, “What you do makes a difference, and you have to decide what kind of difference you want to make.”¹⁷ For generations, millions of women were denied the opportunity to answer that question for themselves.

We usually describe the last century as though women were the principal beneficiaries of expanded opportunity. In one sense they certainly were. But civilization benefited even more. Every physician who saved a life after finally being admitted to medical school, every scientist who made a discovery, every entrepreneur who created jobs, every teacher who inspired students, and every engineer who designed something safer contributed far beyond her own career.

Are Women Better Leaders?

At this point, the question almost asks itself. If societies benefited by expanding opportunities for women, does that mean women are actually better leaders than men?The evidence suggests a more interesting answer.

Over the past several decades, psychologists, economists, and organizational researchers have studied leadership in businesses, governments, schools, hospitals, and the military. Thousands of studies have produced a remarkably consistent conclusion. Women, on average, tend to score somewhat higher in collaboration, mentoring, communication, and what psychologists call transformational leadership.¹⁸ Men, on average, score somewhat higher in competitiveness, assertiveness, and willingness to accept risk.¹⁹

There are countless decisive women and countless collaborative men. Leadership, it turns out, depends far less on chromosomes than on matching the right person to the right problem. A company facing bankruptcy may need someone willing to make painful decisions quickly. A hospital recovering from years of conflict may benefit more from someone who excels at rebuilding trust. Different situations reward different strengths.

• Large international studies find women receive slightly higher overall leadership effectiveness ratings.²⁰
• Women remain substantially underrepresented among Fortune 500 CEOs.²¹
• Men continue to hold most positions associated with political and military power worldwide.²²
• Leadership has always been more complicated than biology.

The COVID-19 pandemic briefly reignited this debate when several countries led by women appeared to perform especially well during the early stages of the crisis. Headlines quickly proclaimed that women were simply better leaders.

Those countries differed in wealth, geography, healthcare systems, population density, public trust, demographics, and political culture. Any of those factors could have influenced the outcome. Researchers spend years trying to untangle those variables because the real world rarely cooperates with simple explanations.

Ice cream sales and shark attacks both increase during the summer. No one seriously believes vanilla cones are attracting great white sharks. The world is filled with relationships that appear obvious until someone examines them more carefully.

History tells a similar story. Humanity has produced extraordinary female leaders and disastrous female leaders. It has produced extraordinary male leaders and disastrous male leaders. Character, judgment, intelligence, humility, timing, and sometimes plain luck have always mattered far more than sex.

As Margaret Mead wrote, “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.”²³ She wasn’t describing women or men. She was describing capable people willing to accept responsibility.

Perhaps that’s the quiet lesson hidden inside the research. The great achievement of the past century wasn’t proving that women lead better than men. It was abandoning the assumption that leadership could be predicted before meeting the leader.

For generations, societies selected presidents, judges, professors, physicians, scientists, military officers, and chief executives from only half the available population while convincing themselves they had conducted a thorough search. Looking back, that seems less like confidence than a remarkable failure of imagination.

The Male Hobby of Dying

One of the stranger discoveries in public health is that if you want to understand the differences between men and women, don’t begin by studying how they live. Study how they die.

Across virtually every country on Earth, women outlive men. In the United States, the difference averages about five to six years, depending on the year being measured.²⁴ We repeat that statistic so often that it has almost lost its ability to surprise us. If two groups living in the same country differed by that much for almost any other reason, epidemiologists would treat it as a major public health concern.

Biology explains part of the story. Estrogen appears to protect women against cardiovascular disease before menopause, and two X chromosomes provide a degree of genetic redundancy that men simply don’t possess.²⁵ But biology doesn’t explain everything. The size of the life-expectancy gap changes across countries and over time, suggesting that culture influences mortality almost as much as genetics.

Those cultural lessons begin early. Boys are often taught to be tough, solve problems alone, hide vulnerability, and avoid asking for help. Those messages can produce courage and resilience. They can also produce men who delay seeing physicians, ignore symptoms, and mistake endurance for good health.

The statistics are remarkably consistent. Men account for the overwhelming majority of workplace deaths, particularly in construction, mining, logging, commercial fishing, and other dangerous occupations. They die more often in motor vehicle crashes, more often from homicide, more often from drug overdoses, and roughly four times as often by suicide.²⁶ None of those numbers suggest that men are somehow defective. They suggest that biology and culture have been shaping one another for a very long time.

• Men account for more than 90 percent of workplace fatalities in the United States.²⁷
• Men die by suicide at roughly four times the rate of women.²⁸
• Men are significantly more likely to die by homicide.²⁹
• Men are less likely to receive preventive medical care.³⁰
• Apparently, “I’m fine” has become an unofficial medical diagnosis.

One of the least dramatic findings in medicine may also be one of the most important. Women are generally more likely to schedule annual physicals, undergo preventive screening, and mention symptoms before they become emergencies. Men often arrive later, considerably sicker, and still convinced they probably didn’t need to come in.

As Wanda Sykes once joked, “Men think going to the doctor is admitting defeat.”³¹ Like much good comedy, the joke lands because it exaggerates behavior people instantly recognize.

Psychiatry reveals another paradox. Women are diagnosed with depression and anxiety more often than men, yet men die by suicide at dramatically higher rates.³² Part of the explanation may be that diagnosis requires people to seek treatment. Women, on average, are more likely to discuss emotional distress, maintain emotionally supportive friendships, and ask for help before a crisis becomes overwhelming. Many men continue trying to solve emotional suffering privately through work, alcohol, isolation, distraction, or simple endurance.

Some of the most poignant research examines what happens after the death of a spouse. Widowers experience a substantially greater increase in mortality than widows during the months and years following bereavement.³³ Popular culture speaks of dying from a broken heart, and medicine has confirmed that severe grief can have genuine physical consequences. More often, however, the explanation is less dramatic. Many men eventually discover that their wife was not only their spouse but also their closest confidante, social organizer, and the person quietly holding together much of their emotional world.

Perhaps that’s the lesson hidden inside these statistics. Relationships, preventive healthcare, emotional openness, and the willingness to ask for help rarely seem exciting. They don’t generate headlines or bestselling books. They simply help people live longer.

Medicine Was Built Around Men

One of the great ironies of modern medicine is that while women consistently outlive men, much of twentieth-century medical research quietly treated the male body as the default version of the human body. The decision wasn’t malicious. It was methodological.

Researchers were trying to simplify experiments. Menstrual cycles, pregnancy, menopause, and hormonal fluctuations introduced variables that scientists worried would complicate their results. Rather than designing studies sophisticated enough to account for those differences, many investigators simply excluded women altogether.³⁴ What looked like good experimental design in the short term ultimately produced decades of incomplete medicine.

The consequences reached far beyond research laboratories. Physicians prescribed medications, estimated disease risk, interpreted symptoms, and developed treatment guidelines using evidence that came disproportionately from studies of men. The underlying assumption was simple: women were essentially smaller men whose biology differed mainly in reproductive organs.

• Until the early 1990s, women were routinely underrepresented or excluded from many clinical drug trials.³⁵
• The National Institutes of Health Revitalization Act of 1993 required federally funded clinical research to include women and minorities.³⁶
• Heart disease remains the leading cause of death among women.³⁷
• Science often advances by discovering that yesterday’s “obvious” assumptions weren’t.

Heart disease provides a perfect example. Most people picture a heart attack as a middle-aged man clutching his chest before collapsing to the floor. Women certainly experience chest pain, but they are also more likely to present with fatigue, nausea, shortness of breath, jaw pain, upper back discomfort, or simply a profound sense that something is terribly wrong.³⁸ For years, many women with those symptoms were told they were anxious, exhausted, or suffering from indigestion when they were actually experiencing heart attacks. Even today, women are more likely to experience delays in diagnosis and treatment.

Pain tells a similar story. Numerous studies have found that women are more likely to have their pain minimized or attributed to emotional causes than men.³⁹ That’s rarely because physicians consciously choose to dismiss women. Most doctors genuinely want to help. The problem is subtler than individual prejudice. Medicine inherited assumptions that gradually became invisible simply because everyone had grown accustomed to them.

Psychiatry has undergone a similar transformation. Early descriptions of autism and ADHD were based largely on boys, which meant generations of girls learned to camouflage their symptoms rather than being recognized. Many became experts at observing classmates, memorizing social rules, suppressing behaviors that attracted attention, and quietly exhausting themselves trying to appear “normal.” By adulthood, countless women had accumulated years of self-doubt before finally discovering that nothing had been wrong with their intelligence. Medicine had simply been looking for the wrong picture.⁴⁰

I’ve watched that change unfold during my own career. Twenty years ago, clinicians were taught to picture a little boy bouncing off classroom walls whenever ADHD was mentioned or a socially withdrawn boy lining up toy trains whenever autism entered the conversation. Today we recognize that many girls struggled just as profoundly while attracting almost none of the attention. They weren’t overlooked because they lacked symptoms. They were overlooked because they didn’t resemble the patients researchers had originally studied.

As Bernadine Healy, the first woman to direct the National Institutes of Health, argued, women often became victims of what she called the “Yentl Syndrome.”⁴¹ Borrowing the title of Isaac Bashevis Singer’s story, she observed that women frequently received appropriate diagnosis and treatment only when they presented the way men did. If their illnesses looked different, they were more likely to be misunderstood.

Medicine has become far better at asking these questions. Researchers now routinely examine differences in drug metabolism, cardiovascular disease, autoimmune disorders, pain, immune function, and brain development. Looking back, the lesson extends well beyond medicine. Science progresses whenever curiosity becomes stronger than certainty.

Equality...and Another Full-Time Job

History has a habit of solving one problem while quietly introducing another. As opportunities for women expanded throughout the twentieth century, many people assumed that one set of expectations would simply replace another. Women would enter professions once closed to them, become financially independent, and enjoy the same freedom to shape their lives that men had long taken for granted.

Women entered medical schools without leaving motherhood behind. They became attorneys without abandoning responsibility for aging parents. They became professors, executives, scientists, and business owners while often remaining the people expected to remember birthdays, schedule dentist appointments, organize holidays, buy groceries, arrange childcare, and somehow keep family life running smoothly. Instead of replacing one role with another, modern life often stacked one on top of the other.

Sociologists noticed the pattern decades ago, describing the unpaid work that begins after the paid workday ends as the “second shift.”⁴² More recently, researchers have focused on the “mental load,” the invisible work of planning, anticipating, remembering, and organizing that keeps families functioning.⁴³ Someone remembers which child needs new shoes, notices the dog is almost out of food, schedules the dentist six months in advance, realizes the permission slip is still sitting on the kitchen counter, and somehow keeps track of everyone’s lives without anyone noticing the effort involved.

• Women continue to perform substantially more unpaid caregiving than men.⁴⁴
• Mothers remain more likely than fathers to interrupt or reduce their careers while raising children.⁴⁵
• Women continue to shoulder most of the family’s invisible organizational work.⁴⁶
• The smoothest-running households are often powered by work no one sees.

Invisible work has an unfortunate characteristic. Success is measured by the absence of problems. Nobody applauds because the prescriptions were refilled on time, the electricity bill was paid, the refrigerator remained stocked, or the pediatrician appointment wasn’t forgotten. Those accomplishments become visible only when they fail.

After years of listening to patients, I’ve become convinced that this arithmetic explains far more emotional exhaustion than most people appreciate. Many of the women who sit across from me are exceptionally capable. They are physicians, teachers, attorneys, engineers, scientists, executives, and entrepreneurs. They solve complex problems throughout the day, then return home to solve another collection of problems that may never appear on a résumé but are no less essential to keeping a family functioning.

To be fair, men have changed as well. Fathers today generally spend far more time raising children than fathers did a generation or two ago, and younger couples divide parenting and household responsibilities much more evenly than their parents often did.⁴⁷ Expectations have expanded for everyone. Men are now expected not only to provide financially but also to become deeply engaged parents, emotionally available partners, and active participants at home.

As Brené Brown writes, “Perfectionism is not the same thing as striving to be your best.”⁴⁸ Modern life often blurs that distinction. Somewhere along the way, success quietly stopped meaning doing one thing well and started meaning doing everything well, all at once.

Perhaps that’s one of progress’s quieter ironies. Expanding opportunity made life richer, fairer, and more interesting. It also made it more complicated. Every generation inherits freedoms its grandparents never imagined, along with expectations its grandparents never carried.

So Why Aren’t Women Happier?

If someone from 1926 could spend a week walking around America today, they would probably reach an obvious conclusion. Women, they would assume, must be happier than they have ever been.

The evidence would seem overwhelming. Women vote, own homes and businesses, become physicians, judges, scientists, airline pilots, entrepreneurs, and military officers. They earn most bachelor’s, master’s, and doctoral degrees and enjoy freedoms their grandmothers could scarcely have imagined. If opportunity alone determined happiness, this should be the happiest generation of women in history.

Yet that isn’t what psychiatrists have been seeing.

Over the past two decades, anxiety, depression, eating disorders, self-harm, perfectionism, and loneliness have all increased among girls and young women.⁴⁹ Every week I meet bright, thoughtful, accomplished women who somehow remain convinced they’re falling behind. Some have successful careers. Others have families they deeply love. Many have both. Yet an astonishing number describe themselves as failures because they haven’t managed to excel in every part of their lives at the same time. The contradiction is difficult to ignore.

Expanding opportunity removed barriers that never should have existed, but it never promised certainty, belonging, confidence, or purpose. Those have always been different problems. Human beings have a remarkable tendency to assume that once one obstacle disappears, happiness will quietly move in to occupy the empty space. Life rarely works that way.

Whenever this subject comes up, someone inevitably announces that they’ve discovered the explanation. It’s social media. Or smartphones. Or feminism. Or capitalism. Or helicopter parenting. Or the decline of religion. Human beings have always preferred simple explanations because they allow us to stop asking questions.

Psychiatry teaches the opposite lesson. Most emotional suffering develops the way storms do. Many conditions come together before anything breaks. Perfectionism collides with loneliness. Childhood experiences collide with adult responsibilities. Grief arrives just as work becomes overwhelming. Financial stress meets relationship conflict. Rarely does anyone arrive in my office because of one thing.

• Adolescent girls report substantially higher rates of anxiety than boys.⁴⁹
• Women are diagnosed with depression nearly twice as often as men.⁵⁰
• Women are more likely to seek treatment, making diagnosis more likely.⁵¹
• Human suffering almost never has a single cause.

Social media almost certainly deserves part of the blame, but only part. For most of human history, comparison occurred within villages, neighborhoods, classrooms, and workplaces. Today’s teenager compares herself with every influencer, entrepreneur, athlete, actor, musician, and perfectly filtered stranger on Earth before breakfast. Evolution prepared our brains for small communities. We handed them the internet.

Perfectionism may be even more important. Success quietly stopped meaning doing one thing well and started meaning doing everything well. Build a career. Raise emotionally healthy children. Stay physically fit. Care for aging parents. Save for retirement. Exercise. Volunteer. Read more. Meditate. Travel. Sleep eight hours. Remain grateful.

As Sherry Turkle observed, “Technology proposes itself as the architect of our intimacies.”⁵² Never before have people known so much about one another’s lives while understanding so little about one another’s inner worlds. We know where everyone vacations, what they eat, and which filter they used on Instagram. Yet many people struggle to identify the one person they would call if everything suddenly fell apart.

Perhaps that’s the real lesson. Equality was never supposed to eliminate loneliness, grief, insecurity, or the search for meaning. Those belong to the human condition, not to one sex or the other. What equality has done is something far more important.

It has allowed millions of women to decide for themselves what kind of life is worth building.

The Experiment Continues

By the time I finished writing this article, I realized it had quietly changed subjects. It began as an article about women. It ended as an article about civilization.

History often reduces social change to a sequence of elections, court decisions, legislation, and famous speeches. Those moments matter, but they rarely explain how societies actually change. Most revolutions occur so gradually that they become visible only in hindsight. A young woman applies to medical school because no one tells her she shouldn’t. An engineer solves a problem from a perspective everyone else overlooked. A scientist asks a question that had never occurred to her predecessors. A teacher changes the direction of a student’s life without ever knowing it. Decades later, those ordinary moments accumulate until society looks back and realizes it has become something different.

The story isn’t simply that women entered medicine, science, business, education, politics, and the professions. The larger story is that civilization finally began making fuller use of its own abilities. Every physician who saved a life after previous generations had been denied admission to medical school, every entrepreneur who built a company, every scientist who expanded human knowledge, every teacher who inspired another generation, and every judge who strengthened the rule of law became part of an investment whose returns extended far beyond any individual career.

• Societies prosper when more people are allowed to contribute.⁵³
• Diverse teams consistently outperform more homogeneous ones on many complex problem-solving tasks.⁵⁴
• Talent has never respected the categories societies imposed upon it.
• Excluding ability has always been more expensive than discovering it.

As Hillary Clinton said at the 1995 Fourth World Conference on Women in Beijing, “Human rights are women’s rights, and women’s rights are human rights.”⁵⁵ The line is usually remembered as a statement about equality. It is also a statement about progress. Every expansion of human rights eventually becomes an expansion of human possibility. Public education strengthened societies because more minds were allowed to develop. Vaccination strengthened societies because more people survived to contribute. Opening opportunities to women followed the same pattern. The immediate beneficiaries were women. The lasting beneficiaries were all of us.

None of this suggests that the work is finished. Women continue to face discrimination, violence, unequal caregiving responsibilities, and expectations that often exceed what any individual could reasonably satisfy. Men continue to die younger, die by suicide at much higher rates, avoid preventive medical care, and struggle with loneliness in ways we are only beginning to understand. Every generation solves problems that once seemed permanent, only to discover a new collection of challenges waiting on the other side.

That may simply be how progress works. It removes barriers without removing uncertainty. It creates opportunity without guaranteeing fulfillment. It enlarges the number of people able to shape the future, but it never eliminates the timeless questions that accompany being human.

Looking back, the greatest discovery of the past hundred years wasn’t that women proved capable of extraordinary things. They had always been capable. The real discovery was that civilization became wise enough to stop wasting so much of itself.

Notes and Sources

1. Centers for Disease Control and Prevention. National Center for Health Statistics. Suicide, mortality, and life expectancy reports. Also see Of Boys and Men by Richard V. Reeves (Brookings Institution Press, 2022).

2. United States Census Bureau. Annual Population Estimates.

3. National Center for Education Statistics. The Condition of Education (latest editions).

4. Gloria Steinem. Outrageous Acts and Everyday Rebellions. New York: Holt, Rinehart and Winston, 1983.

5. Nineteenth Amendment to the United States Constitution (1920); Voting Rights Act of 1965.

6. Equal Pay Act of 1963.

7. Civil Rights Act of 1964.

8. Equal Credit Opportunity Act.

9. Title IX.

10. Marital rape criminalization in the United States. See also National Coalition Against Domestic Violence legal history summaries.

11. Association of American Medical Colleges. Physician Workforce Data Reports; American Bar Association; National Center for Education Statistics.

12. Ruth Bader Ginsburg. My Own Words. New York: Simon & Schuster, 2016.

13. Jane Goodall. Reason for Hope. New York: Warner Books, 1999.

14. Alice H. Eagly and Linda L. Carli. Through the Labyrinth: The Truth About How Women Become Leaders. Harvard Business Review Press, 2007.

15. Alice H. Eagly, Mary C. Johannesen-Schmidt, and Marloes L. van Engen. “Transformational, Transactional, and Laissez-Faire Leadership Styles.” Psychological Bulletin.

16. Fortune. Annual Fortune 500 CEO reports; UN Women. Women in Political Leadership reports.

17. Margaret Mead. Culture and Commitment. Natural History Press, 1970.

18. Marianne J. Legato. Why Men Die First. Palgrave Macmillan, 2008.

19. United States Bureau of Labor Statistics. Census of Fatal Occupational Injuries.

20. National Institute of Mental Health; Centers for Disease Control and Prevention. Depression, suicide, and help-seeking statistics.

21. Nicholas A. Christakis and Felix Elwert. “Widowhood and the Risk of Mortality.” American Journal of Public Health 98, no. 11 (2008): 2092–2098.

22. National Institutes of Health. NIH Revitalization Act of 1993; Institute of Medicine. Exploring the Biological Contributions to Human Health (2001).

23. American Heart Association. Heart Disease and Stroke Statistics; National Heart, Lung, and Blood Institute.

24. Bernadine Healy. “The Yentl Syndrome.” New England Journal of Medicine 325 (1991): 274–276.

25. Tony Attwood. The Complete Guide to Asperger’s Syndrome. Jessica Kingsley Publishers, 2007; Judith Gould. Research on autism in girls and women.

26. Arlie Russell Hochschild. The Second Shift. New York: Viking, 1989.

27. Eve Rodsky. Fair Play. G.P. Putnam’s Sons, 2019; Organisation for Economic Co-operation and Development. Time-use and unpaid labor reports.

28. Brené Brown. The Gifts of Imperfection. Hazelden, 2010.

29. Sherry Turkle. Alone Together. Basic Books, 2011.

30. Scott E. Page. The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools, and Societies. Princeton University Press, 2007.

31. Hillary Rodham Clinton. Address to the Fourth World Conference on Women, Beijing, China, September 5, 1995.

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