When the Hospital Came Home

My mother needed hospital care, and she got it. But the hospital also took her sleep, her movement, and every last bit of control over her own day. Then we qualified for a program that sent the hospital to her house instead, and almost everything except the medicine changed.

I am a radiologist. I have spent years inside hospitals, reading images for patients I rarely meet, trusting that the system on the other end of my report works the way it is supposed to. Then my mother was admitted, and I found out what the other side of that system feels like when you are the one sitting in the chair.

She does not speak English. That single fact reorganized our whole family. One of us had to be in the room with her at all times, so my siblings and I built a rotation and lived inside it. The room itself was lovely. Big windows, warm light, a recliner that folded back into something the brochure would probably call a bed.

It was not a bed. I know, because I spent nights in it.

The part nobody warns you about

Here is what I did not expect: the exhausting part was not the worry. It was the interruptions.

Vitals at midnight. A blood draw before dawn. An IV pump alarming at two in the morning. Someone coming in for weights, then someone else for the morning labs. My mother never got a full night. Neither did I. We were both awake at 4 a.m. in a room designed to make sure nothing was ever missed, which also meant nothing was ever quiet.

And then daylight brought the other problem: waiting. Several subspecialists were consulting on her case, and I never knew when any of them would appear. Rounds happened sometime. The nurse came sometime. The doctor will see you now, except no one could tell you when now was going to be.

So I did not leave. I skipped meals and held it and stayed put, because stepping out for ten minutes meant possibly missing the one conversation I had been waiting fourteen hours to have. I could not pick up my daughter. I could not be in two places. I sat in a beautiful room and felt completely trapped in it.

Meanwhile my mother sat too. Bed, chair, bed. Day after day, a woman who runs her own household barely moved twenty feet.

The care was excellent. The experience was not. Those turn out to be two different things, and the difference has a name in the literature.

The hospital itself is a stressor

In 2013, the Yale cardiologist Harlan Krumholz gave this a name in the New England Journal of Medicine: post-hospital syndrome. His argument is that the month after a hospital stay carries a broad, elevated risk of getting sick again, and much of that risk comes not from the original illness but from what the hospital did to the person while treating it. Sleep gets shredded. Nutrition suffers. People stop walking. Days lose their edges.

Once I read that, everything I had watched in that room stopped feeling like bad luck and started looking like a predictable pattern. The numbers back it up.

47 min

Less sleep per night in the hospital than the same patients got at home

683 older medical inpatients, four hospitals (Smichenko 2025)

57%

Of observed daytime hours, inpatients of all ages spent lying in bed. Nine percent standing or walking.

132 inpatients, behavioral mapping (Mudge 2016)

30%

Of hospitalized older adults go home less able to do a basic daily task than when they arrived

Meta-analysis, 7,375 patients (Loyd 2019)

That last one has a clinical name too: hospital-associated disability. Someone walks in able to bathe or dress themselves and walks out unable to, and the thing that took it away was the stay, not the illness. A large prospective study found that in-hospital mobility, continence care, and length of stay together explained 64% of the variation in who declined by discharge. Those are all things a system chooses.

Bed rest is often not even a medical decision. In a study of 498 hospitalized adults over 70, a third had bed rest ordered at some point, and among the least mobile patients, nearly 60% of those bed rest episodes had no documented medical reason at all. We immobilize people out of habit.

The sleep piece is just as fixable and just as stuck. When researchers asked patients, physicians, and nurses what wrecks sleep in the hospital, all three groups named the same top three: pain, vital signs, and tests. Everyone knows. It happens anyway.

And the language problem sitting underneath all of it

My family's rotation existed because my mother could not advocate for herself in English. I used to think of that as our private logistics problem. It is actually a documented safety issue.

In a study of 1,666 families across seven North American hospitals, children whose parents were not comfortable speaking English in medical settings had roughly twice the odds of experiencing a harm caused by their medical care (17.7% versus 9.6%). A companion study across 21 hospitals found families with limited English proficiency were dramatically less likely to speak up when something looked wrong, or to question a clinician's decision. Both studies looked at hospitalized children rather than adults, so I hold the specific numbers loosely. The direction is not in doubt, and it matched our experience exactly. Being physically present was our workaround for a system that could not hear her.

Then we qualified for hospital at home

Hospital at home is not new. Versions of it have run for decades in Australia and the United Kingdom. What is new in the United States is scale, and the reason is technology plus a Medicare waiver. The model works like this: a physician-led team runs your care from a command center, in-person visits come to your house, and everything that can be done remotely is. You are formally an inpatient. You are just an inpatient in your kitchen.

A program sets you up at home with a tablet, a blood pressure cuff, a scale, an oxygen monitor, an emergency alert you wear, a direct-dial phone to the command center, plus a wifi extender and a backup power supply because the whole thing depends on staying connected. Physicians, nurse practitioners, pharmacists, nurses, social workers, and paramedics all work off the same plan.

My mother qualified. Here is the day that followed.

Same illness, same medicine, two different days. A composite of our experience, not a chart of measured data. The hatched blocks on the left are the part that wore me down: care that was definitely coming, at a time nobody could tell me.

What actually changed

My mother started moving. Not because anyone prescribed it, but because she was in her own house and there was laundry to fold and dishes in the sink. She got up. She walked around. She did her own things. Within a day she was doing more than she had done in a week of lying in a beautiful room.

I slept. Fully, in my own bed, and nobody came in at 2 a.m. I picked my daughter up. I was in the same building as both the person I care for and the person I am raising, which had felt impossible for weeks.

And the schedule became ours. The nurse came at a time we knew. The blood draw had a window. I could actually schedule my mother's visit with the primary team, which meant I could plan a day around it instead of surrendering the day to it. Consultants still appeared without warning, but they appeared on a screen for a few minutes rather than being an eight-hour vigil.

There was one more thing I did not anticipate. In the hospital, I felt guilty calling the nurse. Towels, another gown, a cup of coffee: I knew how busy she was and I could see her running, so I sat on small needs and let them stack up. At home, a nurse was one button away, twenty-four hours a day, and I used it without hesitation, because now every call I made was actually about my mother's care. The small stuff was just ours to handle. That reallocation felt better for everyone.

It was not only that the care moved. It was that we got the environment back. The medicine stayed the same and the power over the day came home with her.

I thought this was my private observation until I found a study that had written it down. Researchers interviewed patients from a randomized home hospital trial and found that home patients described "a locus of control surrounding their sleep, activity, and environmental comfort" that hospitalized patients simply did not have. That is the whole thing, in the dry language of qualitative research. Not comfort. Control.

Does it actually work, or does it just feel better?

This is where I put my radiologist hat back on, because a good feeling is not an outcome. The honest answer is that hospital at home holds up on safety and wins clearly on experience and activity, while the cost and readmission findings are real but less consistent than the enthusiasm suggests.

Traditional hospital Hospital care at home

Two separate randomized trials. Compare the two bars within a panel, never across panels. The Boston trial (Levine 2020) randomized only 91 highly selected patients at two sites, with 63% of eligible patients declining to participate, so treat those two panels as promising rather than settled. The comfort figure comes from a larger 2025 trial of 1,150 patients (Maniaci 2025).

The strongest single piece of evidence is a randomized trial published in 2025. It randomized 1,150 acutely ill patients across three hospitals to hospital-at-home care or a traditional bed. The combined rate of death or unplanned readmission within 30 days was 17.3% at home and 19.8% in the hospital, which met the trial's bar for showing home care is not worse. No patient died while receiving their hospital care at home. And on comfort, the gap was wide: 84.4% versus 60.9%.

The broader picture, from a Cochrane review of 20 randomized trials covering 3,100 people, is consistent. Hospital at home probably makes little or no difference to death rates or readmissions, probably lowers costs, and probably makes people meaningfully less likely to end up living in a nursing home six months later. That last finding deserves more attention than it gets.

Two honest caveats. First, cost savings are not automatic: when Levine's group ran the same model in rural communities in 2025, the episode cost came out no different from a regular hospital stay, even though patients took roughly seven times more steps per day and rated the experience far higher. Second, almost every one of these trials enrolled carefully selected, relatively stable patients. That is exactly who the program is for, and it is exactly why you cannot generalize the results to everyone in a hospital bed.

Where it is imperfect, including for us

I do not want to write a brochure. We had real friction.

The tablet needed rebooting. We had connection problems. When technology is the spine of your care, the spine occasionally goes out. What made it workable was that the program planned for exactly this: there were two separate backup ways to reach the team while the tablet was being sorted out. Redundancy is not a nice-to-have in this model, it is the safety system. If you are evaluating a program, ask what happens when the internet drops, and do not accept a vague answer.

The bigger caveat is the one the research keeps flagging and the marketing keeps skipping: this model leans on the family. In a study of 125 caregivers assessed in the first 48 hours of a hospital at home admission, 61.6% already met the threshold for high caregiver strain. Interviews with caregivers in the United States and Denmark found the same pattern: they overwhelmingly preferred it to a hospital stay, and they also felt underprepared, unclear about what was their job versus the team's job, and sometimes overwhelmed.

I had three siblings, a flexible enough job, and clinical training. That is not most families. A model that quietly assumes a capable, available caregiver will work beautifully for people who have one and will not be offered to people who do not. That is an equity problem sitting right in the middle of a very good idea, and it should be designed for rather than discovered later.

If a program is offered to your family, ask these

• Exactly what am I responsible for, and what is the team responsible for? Get it in writing.
• What are the backup ways to reach you if the tablet or the internet fails?
• How fast can someone physically get to the house, and who is that person?
• Can we schedule the daily physician visit, or does it just happen?
• What triggers a transfer back to the hospital, and how does that work at 3 a.m.?
• Is interpretation built into every visit, or does the family have to arrange it?

Why I am excited about this beyond my own family

For twenty years, nearly every effort to improve the patient experience has aimed at making the in-person visit better. Nicer rooms. Better food. Softer lighting. My mother's room proved the ceiling on that strategy: it was a genuinely beautiful room, and it still took her sleep, her movement, and her control, because those losses are structural rather than decorative.

Remote monitoring plus a command center does something a renovation cannot. It keeps the medicine and drops the institution.

And it frees a bed. Australia's Victorian hospital-in-the-home program was described in one paper as "the 500-bed hospital that isn't there." Every stable patient treated at home is a bed available to someone who is critically ill and genuinely needs hands on them, in a country where capacity is the binding constraint on almost everything. My mother going home was not just better for my mother. It was better for whoever got that room.

The policy question is settled for now. Congress extended the Medicare waiver through 2030 as part of the Consolidated Appropriations Act, 2026. As of that extension, 366 programs across 139 health systems in 37 states were approved to deliver acute hospital care at home. Five years of stability is enough runway for health systems to actually build rather than pilot.

Framed against the Quintuple Aim, the goals most of us in health care now organize around, this model plausibly moves four of the five at once: outcomes hold, experience improves substantially, costs trend down in most settings, and freed capacity helps the sickest patients. The fifth, equity, is the one that will not take care of itself. It depends entirely on whether programs get built for families who do not already have a spare adult and a strong wifi signal.

What I keep coming back to

My mother received the same medicine either way. Same labs, same monitoring, same physicians. What changed was that she got to fold her own laundry, sleep through the night, and eat lunch at her own table, and I got to be a daughter and a mother on the same day instead of choosing.

For years I assumed the goal was a better hospital. I think the actual goal is needing the hospital for less.

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How this piece was built

I structured the story on Randy Olson's And, But, Therefore framework, which is a simple way to keep a narrative from collapsing into a list of facts. Three published frameworks shaped how I read my own experience: Krumholz's post-hospital syndrome for why the hospital itself is a stressor; the Age-Friendly Health Systems 4Ms (What Matters, Medication, Mentation, Mobility) for naming what changed at home; and the four core concepts of patient- and family-centered care (respect and dignity, information sharing, participation, collaboration), which is where the agency argument actually lives.

AI disclosure. I wrote this from my own experience and my own point of view. I worked with Claude (Anthropic) as a research and drafting partner: it searched PubMed and Consensus for the peer-reviewed evidence cited here, verified the trial numbers against the source abstracts, identified the narrative and conceptual frameworks above, produced the two figures, and helped me organize and tighten the draft. I directed the argument, supplied the experience, and reviewed every claim and citation before publishing.

References

1. Maniaci MJ, et al. Safety in a hybrid hospital-at-home program versus traditional inpatient care: a pragmatic randomized controlled trial. J Hosp Med. 2025;20(11):1174-1184. doi:10.1002/jhm.70076
2. Levine DM, et al. Hospital-level care at home for acutely ill adults: a randomized controlled trial. Ann Intern Med. 2020;172(2):77-85. doi:10.7326/M19-0600
3. Levine DM, et al. Hospital-level care at home for adults living in rural settings. JAMA Netw Open. 2025;8(12):e2545712. doi:10.1001/jamanetworkopen.2025.45712
4. Levine DM, et al. Hospital-level care at home for acutely ill adults: a qualitative evaluation of a randomized controlled trial. J Gen Intern Med. 2021;36(7):1965-1973. doi:10.1007/s11606-020-06416-7
5. Edgar K, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev. 2024;3(3):CD007491. doi:10.1002/14651858.CD007491.pub3
6. Krumholz HM. Post-hospital syndrome: an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100-102. doi:10.1056/NEJMp1212324
7. Loyd C, et al. Prevalence of hospital-associated disability in older adults: a meta-analysis. J Am Med Dir Assoc. 2020;21(4):455-461.e5. doi:10.1016/j.jamda.2019.09.015
8. Brown CJ, et al. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc. 2004;52(8):1263-1270. doi:10.1111/j.1532-5415.2004.52354.x
9. Zisberg A, et al. Hospital-associated functional decline: the role of hospitalization processes beyond individual risk factors. J Am Geriatr Soc. 2015;63(1):55-62. doi:10.1111/jgs.13193
10. Mudge AM, et al. Poor mobility in hospitalized adults of all ages. J Hosp Med. 2016;11(4):289-291. doi:10.1002/jhm.2536
11. Grossman MN, et al. Awakenings? Patient and hospital staff perceptions of nighttime disruptions and their effect on patient sleep. J Clin Sleep Med. 2017;13(2):301-306. doi:10.5664/jcsm.6468
12. Smichenko J, et al. Sleep trajectory of hospitalized medically ill older adults. Sleep. 2025;48(5):zsaf013. doi:10.1093/sleep/zsaf013
13. Khan A, et al. Association between parent comfort with English and adverse events among hospitalized children. JAMA Pediatr. 2020;174(12):e203215. doi:10.1001/jamapediatrics.2020.3215
14. Khan A, et al. Association of patient and family reports of hospital safety climate with language proficiency in the US. JAMA Pediatr. 2022;176(8):776-786. doi:10.1001/jamapediatrics.2022.1831
15. Duhamel S, et al. Caregiver burden at the onset of acute hospital-at-home. J Am Geriatr Soc. 2026;74(8):2338-2348. doi:10.1111/jgs.70573
16. Bertelsen KB, et al. When the home becomes the setting for hospital treatment: a qualitative study of relatives' experiences. J Adv Nurs. 2025;82(1):567-579. doi:10.1111/jan.16955
17. Montalto M. The 500-bed hospital that isn't there: the Victorian Department of Health review of the Hospital in the Home program. Med J Aust. 2010;193(10):598-601. PMID 21077817
18. Nundy S, Cooper LA, Mate KS. The Quintuple Aim for health care improvement. JAMA. 2022;327(6):521-522. doi:10.1001/jama.2021.25181

Peer-reviewed sources were located through PubMed and Consensus. Nothing in this post describes anyone's diagnosis or protected health information.

What a Year of Building AI Workflows Actually Looks Like

Most conversations about AI in radiology ask whether it will read the images. That has never been the part of my job that consumes me. What consumes me is everything stacked around the images: the report I have to reconcile against six prior studies, the lecture that needs twelve good cases pulled from ten years of archives, the call schedule that has to satisfy a dozen rules, the license I have to renew on a website designed by someone who has never renewed one.

That is where AI has changed my work. It does not read for me. It clears the ground so I can read.

I want to describe what that actually looks like, because most of what I read about AI in medicine is either breathless or dismissive, and neither matches my experience. Mine has been slower and more mundane than the hype, and more useful than the skepticism.

One note before I start. Everything below runs inside enterprise, HIPAA-covered instances of these tools that my institution has approved, and the research is IRB-approved. None of this involves pasting patient information into a consumer chatbot, and I would not advise anyone to do that.

Reporting: the workflow I measured

Every one of my reports now goes through a custom GPT.

I built a set of them in ChatGPT Enterprise, one per modality, each with disease-specific templates. I dictate into the ChatGPT dictation button rather than into PowerScribe. The dictation is simply better, and that is the whole reason I switched. It is the one thing I use ChatGPT for exclusively, and everything else sits on top of it.

Three of these have become indispensable.

The "MISS" template. I paste in all the prior radiology reports along with my current draft, and it checks my current report against the priors to confirm I have addressed every finding someone described before. This one earns its keep on oncology studies, where a patient may have eight prior scans and a dozen tracked lesions. What goes wrong there is not that I misread something. It is that a finding described eighteen months ago quietly drops out.

The revised-report template. I review the prior findings, tell it what to change, and it writes a new draft.

Fat fraction. I paste in the in- and opposed-phase images with ROIs over liver and spleen, and it hands back a calculation formatted and ready to drop into the report. No calculator, no retyping.

I studied this rather than just claiming it worked. I published the results in Abdominal Radiology, framed through the Unified Theory of Acceptance and Use of Technology, comparing my own baseline period against my post-implementation period across 609 studies.

The findings split cleanly. For outpatient CT, the gains were large. With contrast, my median inter-study interval dropped from 23 minutes to 13. Without contrast, it dropped from 18.5 minutes to 7. Both were significant. For MRI, nothing clear. With contrast the numbers drifted slightly the wrong way, and without contrast the improvement looked big but did not survive correction for multiple comparisons.

I think that null result is the most honest and most useful thing in the paper. Standardized, high-volume CT is exactly the task a templated LLM workflow fits. Complex MRI is not. The cases vary more, the templates are harder to build, and you cannot reduce the reasoning to a form. How well the tool fits the task is doing the real work here, not the model.

Training took ten hours across five days. That is not nothing, and it is worth saying plainly, because people underestimate what you have to put in before you get anything back.

I have also looked at what LLMs do to report accuracy, in a separate study where six radiologists reviewed GPT-4's suggested revisions to 600 of their own finalized abdominopelvic CT reports. GPT-4 flagged something in 91% of reports, but the radiologists accepted only 23% of what it suggested, and most of what it caught was grammar. The clinically meaningful catches were real but uncommon.

I raise that because it tempers my own enthusiasm. The reporting workflow makes me faster and gives me a systematic second pass against priors. It does not make me infallible, and the data do not support anyone who says otherwise, including me.

Teaching: an assistant that does not go home

I am putting together a prostate case review talk for SABI 2026 in Savannah. Historically this takes weeks. Think of the teaching points, hunt through the archive for cases that actually demonstrate them, then chase down the pathology and the clinical follow-up.

Now I brainstorm the case list with Codex, then point it at our enterprise Illuminate instance, which holds the radiology, pathology, and clinical notes together. It pulls the cases while I look them up on PACS and grab images for the slides.

The moment it clicked for me was small. Codex found me a Müllerian duct cyst, but it measured 1.6 cm, too subtle to teach from. I asked for something bigger. It came back with a 15 cm cyst, now too dramatic to represent anything. I asked for something in between and got it.

That exchange took under a minute, and I would never have asked a human assistant to redo the same task three times in a row. It feels like working alongside a superintelligent assistant who does not get tired of my revisions.

Scheduling: the work nobody wants

I run the schedule for the Abdominal Radiology Case Conference, and scheduling has always been the most thankless part of it. Email everyone. Remind them to submit their availability. Reconcile what everyone gives you against the rules. Send calendar invites. Chase the people who never replied.

A student intern and an administrative assistant used to handle it, which worked until someone traveled or a new person came on, and then it broke and left gaps.

Claude now runs the whole cycle: the outreach, the reminders, the rule-based matching, the invites, the follow-ups. So far it is working well.

Our clinical schedule in QGenda got the same treatment. The QGenda rules are not hard, they are just tedious, which is exactly the kind of task worth handing off. I built a Codex project, gave it all the definitions and rules, told it what I wanted, and it took care of it. I have since found I prefer Claude for this particular job, because it gives me a visual dashboard and tracks my schedule as it changes rather than just answering once.

A smaller one in the same vein. I attend a weekly educational meeting where sessions sometimes get cancelled, the instructor changes, and each instructor sends a different Zoom link. All of it arrives by email. Now I hand Claude the email and tell it to update my calendar with the right link and the right instructions, so what is on my calendar always matches what is actually happening that week.

Research: the long tail

I have a project running now on discordant prostate MRI, meaning patients whose MRI was positive but whose biopsy came back negative, across roughly 500 patients. Codex is working through the follow-up MRIs, repeat biopsies, notes, and labs.

I layer the tools, and the layering is the point. I use enterprise Claude to write the instructions for Codex, then to troubleshoot when Codex gets stuck and to double-check what it produces. Having one model brief and audit another has caught things neither would have caught alone.

The small things, which turn out not to be small

I renewed my medical license recently. Anyone who has done it knows the actual work is trivial and navigating the site is miserable. You hunt for the right link, the right page, the right form, before you can start. Codex walked me through it and made it painless.

I mention this because it is typical. So much of my week goes to digging for the right place to begin rather than doing the work itself. Clearing that friction has changed how my days feel more than any single clinical application has.

The same holds for my student interns. I get a new one every year, and retraining them eats a lot of time. The workflows now absorb most of the repetitive tasks, so the time I spend with an intern goes toward actually teaching them something.

And announcing our division's recent publications on social media now runs automatically. Small thing. Off my plate.

Caregiving: the one I would least want to give back

I also care for an aging parent who is ill, which means a steady stream of appointments and a family calendar that has to stay in sync around them. I log into the patient portal, and Claude takes every appointment and puts it on our family Google Calendar, then keeps it updated as things shift.

None of that is hard. It is tedious, it arrives in fragments, and it never really stops. Handing it off lifted a specific kind of mental weight I had stopped noticing I was carrying. Of everything on this list, this is the one I would least want to give back.

What it gave back

Two effects I did not expect.

The reports got better, not just faster. Speed is what I set out to measure. Quality is what I noticed afterward. A systematic second pass against every prior raises the floor on a heavy day, which is exactly the day a finding from eighteen months ago slips through.

I stopped falling behind. The tasks I used to carry around as low-grade dread, the ones that were never hard but were always waiting, are now automated or scheduled. That dread took up more room in my head than the tasks ever took in my week.

What surprised me is what filled the space. I have wanted to write here for years and never had the bandwidth. This post exists because the scheduling, the calendar updates, and the reminders stopped eating the hours I would have spent on it.

It spilled into my personal life too. I have friends who fly first class and take their families on essentially free vacations using credit card points, and they have been telling me about it for years. I always found it interesting in theory, and I was never going to sit down and learn it.

So I built a Claude project instead. I gave it the collective knowledge from the physician points community I follow, the transfer rules between programs and their partners, my credit cards, all of my points accounts, and my travel goals for 2027, and I let it work.

It went through my cards and told me I could drop my Sapphire Reserve and save roughly $800 a year, but that I should downgrade it to a Freedom card rather than cancel it. Downgrading keeps my Ultimate Rewards points alive and avoids putting a closed account on my credit history. I had no idea downgrading was even an option. It also showed me that my other premium cards already carry most of the benefits I was paying the Reserve for, so I had been paying twice for the same thing.

That is one example out of many. The pattern is the same as it is at work. The barrier was never that any of this was difficult. The barrier was that I was never going to make the time.

What I have actually learned

Each tool is good at something different, and it is worth finding out what. ChatGPT dictates best, so all my reports go through it. Codex is where I work across systems. Claude gives me better visual, structured output, which is why my schedule lives there. I did not decide this in advance. I found it by using all three badly for a while.

You have to invest a lot before you get anything back. Building these workflows took hours I did not obviously have, and I still spend many hours a day working with AI. But once a workflow is built, it runs close to seamlessly, and it pays off a little more every week.

Fit matters more than raw capability. My own data showed a large benefit for CT and none for MRI, with the same model and the same radiologist. What differed was the task, not the technology. I would rather build three workflows that fit than ten that impress.

Measure it. I have written before that you cannot improve what you cannot measure, and I meant it about teaching. It applies here too. It would have been easy to feel faster and never check. Some of what I believed held up. Some of it did not.

None of this replaced my judgment. It cleared away the things standing between me and the point where judgment is required. I still read every image and I still own every report. I just spend a much larger share of my day on the part that actually needs me.

If you want to start

A few things I would tell someone at the beginning.

Tell it to double-check its work. Every time. This is the highest-yield instruction I give, and it costs one sentence.

Use two. I keep both Claude and ChatGPT, personal and enterprise. Ask them the same question and you get different answers, and the difference is the useful part. It is complementary rather than duplicative, like having two very smart consultants who think differently. I often use one to audit the other.

Watch a short video. I got started with Codex from one 28-minute YouTube video: Learn 95% of Codex in 30 minutes by Riley Brown. That was the whole onboarding.

You do not need to code. I am not a coder. Nothing I described in this post required me to be one.

Start small. You are not going to build Rome overnight. Every workflow here began as one annoying task I decided to hand off, and they accumulated from there.

One thought I keep returning to. I am starting to want a different kind of student intern: someone who supervises and runs AI workflows rather than doing every task by hand. But that only works if the person still understands the workflow deeply. You cannot supervise a process you do not understand, and you cannot tell when the output is wrong if you have never done the work yourself. That is the part that does not get automated.

How I used AI to make this post. Claude and I co-wrote this post. I talked through my workflows in one long unedited brain dump, and Claude turned that into the structure, the section order, and the prose you just read. Claude searched PubMed for my own papers, pulled the exact figures out of them, and added a fourth reference I had forgotten I was an author on. It built all three data figures here from the published numbers. It also fact-checked me: it cut a claim I made that my reports contain no mistakes, because my own GPT-4 paper does not support that, and it caught a broken link to our case conference channel before this went live. I gave it my writing preferences and it applied them. I read every line, changed what I wanted changed, and approved the final version. The experience and the opinions are mine.

Opinions are my own.

References

• Tan N. Large language model-assisted radiology reporting in a single-radiologist implementation: a retrospective cohort study interpreted through a UTAUT lens. Abdominal Radiology (NY). 2026. doi:10.1007/s00261-026-05524-y
• Mayes CJ, Reyes C, Truman ME, et al. Improving radiology reporting accuracy: use of GPT-4 to reduce errors in reports. Abdominal Radiology (NY). 2025;51(1):513-520. doi:10.1007/s00261-025-05079-4
• Reyes C, Nguyen E, Alexander LF, et al. Beyond Human Limits: The Promise and Pitfalls of Large Language Models in Radiology Research. Journal of Computer Assisted Tomography. 2025;49(4):545-553. doi:10.1097/RCT.0000000000001709
• Gerbaud AF, Berguido de la Guardia M, Booth SC, et al. Process Improvement Before Artificial Intelligence and Automation: Building Trust With the Understand-Transform-Sustain Framework. Mayo Clinic Proceedings: Innovations, Quality & Outcomes. 2026;10(4):100725. doi:10.1016/j.mayocpiqo.2026.100725

Replacing Self with Others

I attended my first meditation week long retreat and had a transformative experience (New Kadampa Tradition Mountain Retreat, Williams AZ, founder Kelsang Gyatso). Like many others, I was grappling with balancing work, family, and personal life. Despite being in a much better position than countless individuals worldwide, the elusive concept of work-life balance remained a challenge for me.


The week long meditation retreat transformed the way I thought, specifically it introduced the idea of how to reframing my approach to the world. One of the primary teachings was the idea of replacing self for others. This means to put my attention on the needs of others instead of putting that attention on myself. This shift in focus has begun to transform my approach to daily challenges.




Object of Attention: Replacing Self for Others

The concept of "Replacing Self for Others" marks a major shift in the way I/we think.  The more attention/concentration we put on an object, the more our mind and bodies channel our energy around that object. So much of the way I thought prior to the Meditation Retreat was about what I needed to do to achieve my personal goals. Take, for instance, my aspiration to advance from Associate to Full Professor. This goal required me to align research, education, and other activities to satisfy the criteria for promotion—a pursuit that was inherently self-centric and a significant source of stress, given the pressure to publish papers and secure grants. However, the retreat inspired me to view my goals through a new lens, focusing on how I could serve others, particularly my students, trainees, and colleagues. Instead of seeing promotion as an end goal, I began to consider how I could contribute to the advancement of those around me. This shift in perspective transformed my approach: aiding my students and trainees in their career paths, with publication efforts emerging as a natural outcome rather than the sole aim. This reorientation not only redefined my objectives but also imbued me with a renewed sense of purpose and energy.




Both goals (#1 full professor vs #2 helping others) achieved similar outcomes, but tapped into very different sources of energy. The energy source that came from Helping Others (#2) was positive, self-energizing force rather than stress/burden from the former (#1). When we frame our efforts and goals towards helping others, the source of energy transforms into something much more powerful and limitless. A mind shifting statement that I read during that one week meditation retreat is the idea that when we are in the service of others, we will never be lonely. This concept suggests that when our thoughts and energies are invested in helping others, feelings of isolation become untenable. Loneliness, along with other feelings such as sadness, depression, and burnout, stems from a self-focused perspective. Redirecting our attention outward effectively dispels these sentiments, anchoring us in a mindset geared towards communal support and connection. It's a very simple idea but execution is much harder. Yet with small practices that I've been able to do in reframing my efforts, the benefits that I've reaped have been tremendous. I'm no longer worried about all the things that I have to do and get done as part of my obligations / commitments. Now I think about what can I do to help those that I can help and how can I do that. Through the latter lens, I become liberated and my ideas are more free flowing and my efforts become more natural.


It's crucial to understand that prioritizing the well-being of others doesn't mean neglecting our own. A fundamental aspect of Buddhist philosophy is the harmonious balance between Compassion and Wisdom. Compassion motivates us to serve others, a hallmark of a fulfilling life. Yet, this must be tempered with Wisdom, recognizing that not all acts of service hold the same weight in terms of importance or impact. Distinguishing between what is essential and what is not allows us to channel our efforts effectively. Taking care of our bodies, health, and overall well-being is imperative. It is only by ensuring our own health and happiness—mentally, physically, and spiritually—that we can genuinely support others. The idea isn't to forsake self-care in favor of altruism; rather, it's to understand that the most effective way to assist others is by maintaining our well-being. This approach not only maximizes our capacity to contribute positively to the lives of others but also enriches our own experience.

If you want to read more, a good starting point is Kelsang Gyatso How To Transform Your Life. You can get a free pdf version online. I got the Kindle version, and used the "Text to Voice" function on my phone to have my phone read the book to me (audiobook version).




Acknowledgement: ChatGPT helped provided edits to the contents.

Interview Tips for Prospective Residency Applicants

As a prospective resident, the interview process can be nerve-wracking and overwhelming. With the rise of virtual interviews, it's more important than ever to be prepared and make a great impression. Here are five tips to help you ace your residency interview:

1. Keep Your Responses Brief and Specific: During an interview, it's important to keep your responses brief and to the point. Use concrete examples that are relevant to the profession to illustrate your point. Avoid tangential or generalizable examples, as the interviewer may lose interest. If the interviewer needs clarification, they will ask.

2. Ask Good Questions: Be prepared with thoughtful questions to ask the interviewer. Examples of good questions include "What differentiates the best trainees from poor performers?" and "What do you suggest for preparing for residency?". Avoid asking poor questions, such as "Do you have questions about my application?" or "Will the growing practice mean more work for residents?".

3. Be Authentic and Spontaneous: While it's good to have an idea of what to respond in terms of common questions, try to be spontaneous and authentic with your answers. Don't over-practice or read off a screen during virtual interviews, as the interviewer can tell.

4. Minimize Distractions: During virtual interviews, it's crucial to minimize distractions. Make sure you're in a quiet, well-lit space with limited background noise. If you have pets, try to keep them out of the room.

5. Do Your Research: Before the interview, take the time to research the institution and learn about it online. If you're really interested, visit the institution. Being able to articulate why you're interested in the specific place can set you apart from other applicants. Personal responses that include having vested interest in the area due family, friends, connections to the institution, or recent visit to the area, or relevance to your interest and aspirations are good examples of illustrating genuine interest.

By following these tips, you'll be well on your way to acing your residency interview. Good luck!

Acknowledgment: #ChatGPT helped me put this together (I gave a summary of key bullet points I wanted in the blog, and then asked it to put it together; and then, I edited it).

Residency Interview Process: My Proposed Design

 I recently read Daniel Kahneman book Noise, as he clarified for me limitations about applicant process interview that I've observed. The residency interview process (or in actuality, most professional job interview process) is subject to so much variability, and depending on the interviewer, applicant, and various uncontrolled conditions, the applicants can do well or not so well. Having experienced a couple of the resident applicant interview cycles, I realized how flawed it was. I felt validated when Kahneman went into depths in his book about exactly the flaws that existed in human judgement that contributed a lot of randomness into the interview process. He then discusses Google's approach to interviewing applicants, which completely resonated with me. What I learned were the following:

1. Only up to 4 interviewers needed. Anymore beyond 4 interviewers is minimal added value.
2. Use structured interview questions, specifically behavior questions, rather than questions about past projects, items on CV. Tailor questions for what the applicant can become (rather than what the applicant currently is capable of).
3. Criteria should be judged independently. At Google, it sounds like the interviewees do video interviews, and response to each question is judged separately / independently, and then an aggregate summary is used.
4. Use ranking instead of score based review. If there are 10 applicants, then the interviewers should rank them 1 to 10, instead of giving each interviewees scores per criterion. Humans are better at ranking than scoring. 
5. Use aggregate scoring (only after independent review). 

In addition, based on Adam Grant's book, Think Again, he discusses the Dunning-Kruger Effect and the inverse relationship between confidence and competence. This is especially problematic with residency applicant interviews because I think applicants who come off as confident, agreeable, and extroverted are often scored highly. However, if the goal of the interview process is to find the applicants who will be the best fit the program, then the current approach may sorely lacking. The Dunning-Kruger Effect suggest that 4th year medical students who are highly competent applicants may have low confidence. In fact, if anything, we want to keep our eyes and ears on high alert for individuals who show humility rather than confidence because humility is associated with competence. This process forced me to rethink my own process which I am developing to figure out how to spot and identify individuals with potential for greatness (the diamond in the rough). 

The process that some of my colleagues in other fields deploy is asking applicants to rate themselves on proficiency is various aspects of the jobs, and then testing them. For example, for a business analytics position, the applicant may be asked to score their proficiency on SQL, Tableau, Power BI, and other tools. Then the applicant is provided the software, and then asked to create / write a few codes. This approach tests both the applicants' self-reported humility, and then competence. 

Sometimes I play a thought exercise and wonder what I would do if I could design a residency applicant interview process, and I would probably do something along these lines:

1. Train and validate an AI model to work alongside to sift through hundreds of applicants and compare /contrast my findings with AI, so that we are reviewing ALL the applicants that would be good fit for the program. The AI would also surface known biases in the program for program's awareness. Often times, we can superficial and shallow filters which can overlook individuals with very high potentials.

2. For the interview process, I like Google's approach and would probably pilot a variant using panel interviews with standardized behavioral questions, with maximum of 4 interviewers. 

3. I would ask interviewers to rank (not score applicants) on key criterion, and then aggregate results to generate final rank list. 

4.  If it was doable / feasible/ permitted, I would ask all interviewees to report their proficiency on key diagnostic radiologists' skills, and then have them generate mock reports of a few radiology studies, and review the reports. 

5. After trainees match and have gone through the early experiences, I would regroup with the interviewers on the outcomes and learn from our strengths and weakness, and make changes accordingly to improve the process, and keep iterating. 

6. At some point in the future, I would train/validate an AI model to read facial expressions (according to Paul Eckmann's line of research) to predict outcomes (e.g. good fit, eventual competence, etc) and use AI to work alongside interview committee members to provide comparative information / data.

A Perpetual Gift of Happiness and Peace

A teaching by Gen-la Kelsang Dekyong at the Kadampa Meditation Center Phoenix on virtuous mindsets had a profound impact on me. Many of us think that if we work hard, then we'll earn a lot of money and we'll be happy; or if we find our soul mate, then we'll be happy; or if we get our dream job (dream home, dream body etc), then we'll be happy. The reverse can be true also. If we never have to seen this [individual, job, object...], then we'll be happy. What happens when these wish(es) come true? We find ourselves not has happy as we thought we'd be. The big house didn't make us happy; neither did the dream job, nor the dream partner.  However, we can adopt mindsets that are perpetually giving and the more we cultivate these mindsets, the the happier we become. We can practice these mindsets now, everyday, and all the time. One of these mindsets is compassion. Compassion is to understand another being and then act in a positive way to improve their well-being. How do we do this? A simple compassionate act we do is to wish them well. I've come to learn that this simple mindset (to wish someone well) has been so effective in improving both the relationships I care about, and more importantly, this mindset has helped with relationships that create discomfort for me. Sometimes, we don’t jive with for whatever reasons with someone, and you might avoid interacting with them because of the awkward nature of those moments. For example, I work with a colleague at work. We are cordial to each other but there is some tension that exists because of a shared project that didn't quite go as expected.It’s  easy for me to get upset, disappointed, or rationalize in my head why the ball got dropped, and point the fingers. However, none of these thoughts help me, the other person or the project. Now, instead, I say in my head "may s/he be happy, may the project success to achieving its goals, and may we move forward together, and with ease". After I say that compassionate statement to myself, all of the sudden, the tension ease, the frustration softens, and mind clears.  If someone cuts you off in the freeway, then instead of cursing or flipping out,  you can cultivate compassionate thought "may s/he be safe, be happy; may the desire that led them to cut me off turn out to be okay for them." You can do this all day long and with all interactions, good or bad, neutral or borderline. When you find yourself passing a judgement/ harboring  a negative thought/ boiling up with  anger, then you can replace that with a compassionate mindset.  This approach helps you, helps others, and gives peace and happiness every single time, with every act, every word, every thought, and every actions.  Over time, the cumulative effect on this simple habit can transform us and bring inner peace and joy that unparalleled to none. All involved share in on the benefits. Now, when I find myself tense thinking about someone, or witness an unpleasant action or hear dismissive words, then I pause, and wish them well. 

Cultivating these positive mindsets is critical because I think people can sense and know how we feel about them without having to say a word. Our thoughts somehow sends an invisible but very palpable vibe to those around us, even when we are not directly interacting with each other. The mindset that we adopt often gets translated in our body language, tone, and our demeanor.  Sometimes, when I'm passing a judgement, I often feel like the other person can read my mind and I get nervous  even though I've said nothing. Now, when I adopt the compassionate mindset, then my body, expression and demeanor relaxes, and I bet the same invisible but positive vibe is felt by the individual.  This approach has completely transformed my day to day interactions especially with the challenging ones. When I interact with a trainee at work that I used to feel equivocal about, instead of adopting a semi-avoidant behavior, I say to my "may I be the best teacher possible, so that this individual may learn, and be effective, etc". My mind and feeling shift immediately, and I feel comfortable around the trainee, and inevitably, the interaction turns positive and productive. When I don't get a request that I've submitted at work, then I say to myself "may this person have the resources s/he needs to be an incredible leader, and to support all those s/he leads.". I even do this with strangers, like our cleaning crew.  I try to wish them well and send them compassionate and positive thoughts and vibes as I pass them by. The power of compassion is endless. With each cultivation of compassionate thought, the happier and more peaceful we become. Try it out. Replace your negative reactions with positive compassionate thoughts; replace your judgements with well-wishing; replace your neutral position with active well meaning  thoughts; share and spread your compassionate vibes to people you know and don't know, and do it with every interaction, and everyday. You'll transform yourself and will increase your peace and joy immediately, with cumulative effects that magnify over time. 

Reframing Life as a Suitcase to prioritize what matters

 Burnout, over commitment, and stress are epidemic, especially among working professionals. Too often we are told to prioritize, focus and say no to anything and all things we do not care for. This approach can be challenging, especially for junior and inexperienced folks. It's easier to agree and then suffer from the over commitment later on. We take our time and our bandwidth for granted; we overestimate how much time and headspace we have and over inflate our abilities. We expect a lot from ourselves, and all of this comes at a cost (lack of free time, underdeveloped relationships, estranged family, etc). When we become stressed, we try to increase the efficiency. We'll cut out our lunch breaks, multi-task, work longer hours, work harder etc. 

I read an article on efficiency, and the article compared Life to a suitcase. We can roll up our clothes, and squeeze in every nook and cranny of the suitcase, but efficiency can only go so far. The space is fixed, and at some point, you'll have to sort the things you want to take, and leave the rest behind. Frequent travelers are pro at packing. They know what the bare essentials and unforgivingly leave behind all things that do not serve a purpose. In the same way, if we reframe life as a suitcase with limited time, and the prospect of travel as experiences in our life, then perhaps we will have a better sense of what to take with us and what to leave behind. What are your bare essentials? If one suitcase equated to 1 year of life, then we only have 80 suitcases to fill, which is not much. Life is short. When I imagine my day, week, month, year in terms of life suitcases, I find it much easier to see clearly what is important, what's borderline, and what definitely is not worthwhile. For example, one consideration I've entertained for sometime is the idea of decreasing my work full time status. If/when I cut back on work (which is easy to say and hard to do), then we can free up time and give ourselves space. But, it comes at the cost of decreased income and the associated cringe that comes with that idea. If instead, I imagine my life suitcase full of money and no free time vs less money but more free time, then the right answer is more obvious to me. Time is a non-renewable, fixed and invaluable resource. The image of packing my life full of work and no time to play sounds unpleasant; instead a suitcase containing just enough while also making space and time to explore, learn, travel, develop relationships seem so amazing. Next time you're stuck and unsure how to move forward, ask you self  what would you take with you in your Life suitcase today, this week, this month? Anything you take means less space for something else. What would an amazing day, an amazing week, an amazing year look like?  Then, pack your life full of all the goodies, and let go of the rest.

Back to Work (In-Person): Reflections

One of my goals is to live and be in the place of abundance...of time, energy, creativity, space, love, compassion, mindfulness. 

In the last two months of working hybrid model, I was fortunate to be able to work in a hybrid model (half on site, and half remote). We've been back on-site fully for a couple of weeks after COVID subsided. 

I've made an interesting observation about myself since transitioning back to traditional on-site model. With hybrid work, I felt like I had more energy after work compared to fully on-site work. I'm attributing (and I could be wrong) the difference in energy levels due to the work space and environment. 

With remote work at home, my workstation is in a room with two large windows with plantation blinds that allow the beautiful, spring warm sunlight to cast its rays in my workspace. The window looks out into my backyard, which is borders Arizona Open Nature Space, full of wild Arizonian flora and wildlife. The room has direct door access to the backyard, and I keep the door slightly ajar throughout the day to allow the wonderful Arizonian desert air with aromatic pollens from the flowering plants to flow into the the room, and chips from the birds resonate into the room. The walls in the room are decorated with photos of my family and friends, and a large canvas of Arizonian succulents. I felt great and after work, I had the vigor and motivation which often led me to go for a run or hike on the trails leading to the nearby mountains. 

With on-site work, well, it's a radiology reading room. The room is dimly lit, and it's in a clean, nature and sunlight-free standard office with dark blue/grey walls. That's it. 

In the book Joyful by Ingrid Fetell Lee, the author discusses the power of ordinary things that create extraordinary happiness. In her book, she discusses the importance of nature and sunlight contributing to our happiness, peace and joy.  She says nature provides a form of mental abundance due to the open space and variations in sensory stimulations we experience. In contrast, being in closed quarters with stagnant air and lack of surrounding nature (artificial or real) make us feel confined and can sap the joy and vigor in our lives. When I spoke to my mother about this phenomena, she drew an analogy to plants. She said humans are like plants, we need nature touches (sun, wind, smell, etc) to thrive.  Otherwise, we slowly wither like a plant deprived of these necessary elements. The effects are more pronounced in children. The effects of nature exposure to children improved cognitive function (increased concentration, greater attention, higher academic performance), better motor coordination, reduced stress, increase social interaction (Strife et al).  Shankar Vedantam deeps dive in to the the idea of how nature improves our lives in his NPR Hidden Brain podcast "Our Better Nature: How The Great Outdoors Can Improve Your Life" In Chicago replica housing projects, high-capacity high rises with green spaces led to 15-20% drop in incidences of violence and police calls compared to housing projects without nature spaces. Artificial sounds of birds projected from audio system embedded in landscapes in high-violent neighborhoods led to a drop of violence by nearly 10%. Breathing air in the nature led to increase in NK cells, which contributed to healthier immune systems compared to air from urban spaces. Research from Well Living Lab, a Delos and Mayo Clinic collaboration, shows that offices with windows improve workers' productivity,  and satisfaction. Centers have coined the term "biophilia". "Bio, life. Philia, meaning love. So we have a love for nature," says Dr. Bauer. Areas with windows which provide natural light and views of the outdoors improve cognitive performance and increase well being. Exposure to nature led to calming effects. Contemporary cultures such as Japan advocate for Forest Bathing to offer an antidote to burnout.  Large tech companies like Facebook are designing work spaces that integrate nature, sunlight and green spaces to improve the well-being of their employees and staff. 

I think the workspace made a significant contribution to the difference in experience. I think days when I have more access to sunlight, view of natural spaces, and other natural sensory stimulations, I feel good all the day long. After I finished work, I felt light, and energetic, and often went for a walk/hike, and in the evenings, I was fully present with my daughter in the evenings. I logged in many more steps. I felt Virya, the Buddhist term for energy and enthusiasm that led one to pursue wholesome activities. In addition, I was in a state of abundance.  When I work in dimly lit, nature-free spaces like the reading room for 10 hours a day, I feel less good after work...and in fact, not infrequently, irritable / stressed.  

Obviously, different people will have different experiences from hybrid working. Some people appreciate the commute-free day, and others benefit from the flexibility.  A good friend told me she went to a yoga class in the middle of the day after she caught on her work. She felt so amazing from the yoga class and came back to the work list feeling great. The yoga time completely transformed her experience. She ended a busy work shift a little healthier, flexible and a lot more happier. Arun Krishnaraj from University of Virginia delivered the New Horizon lecture at 2022 Society of Abdominal Radiology meeting in early March and shared with the audience the need to provide our workforce a hybrid work option, and its importance to promote a healthy and sustainable workforce. Early adopters including New York University, and Cleveland Clinic have offered remote working options due to recruitment needs, and a few of my academic powerhouse friends have moved to these 100% fully remote working models, which have dramatically improved their quality of lives.  There are also negative sides to hybrid working (limited social interactions, potentially suboptimal educational experiences for learners, etc). However, I think the benefits could potentially outweigh the risks if the schedules are designed thoughtfully and iterated to preserve important interactions. 

Having had a taste of how amazing hybrid work option is, I'm super excited about how radiology will be unfolding over the short and intermediate term. I am going to unabashedly put a plug for the RadioGraphics invited commentary I co-authored with a good friend pre-COVID, in 2018 about this topic (https://pubs.rsna.org/doi/full/10.1148/rg.2018180197). When we provide work options, we provide people with an opportunity to live and work in a place and be in the place of abundance. 

Sekhar A, Tan N. Invited Commentary on "Navigating Generational Differences in Radiology". Radiographics. 2018 Oct;38(6):1679-1681. doi: 10.1148/rg.2018180197. PMID: 30303787.

Mental Immunity

I read The Book of Joy by Dalai Lama and Desmond Tutu and I am currently reading Daniel Kahneman Thinking, Fast and Slow. A common theme emerged among the two books that impacted my own views and perspective. Specifically, I've come to develop my higher levels of control through practicing mindfulness through meditation, which then allows me to regulate my emotional range and mental well-being.

More so in the past, and especially during residency, fellowship and early years of clinical practice, the successes and failures impacted me significantly. When I decided to switch from urology residency to radiology residency, I had major doubts about myself, confidence, and competence which created a fiery amount of stress and pressure to work harder, be better, and to "succeed". When I got rejected by the first several grants, I got down and discouraged. Eventually, I came to secure successes with clinical excellence, papers, grants and awards. With each success, I got elated, excited and encouraged. The ebb and flow of career (and perhaps personal) life feels like riding the hamster wheel. It felt like a trap, a dungeon of sorts, being influenced by the successes and failures of my efforts, and being like a boat in the open waters, controlled by the tides.

Over the past year, I came to learn a Buddhist teaching about the value of staying calm and still. Instead of letting mental well-being depend on the pendulum swings of various challenges we face and successes we achieve, we practice control of our natural emotions. By doing so, we can graciously accept both our success and failures equally, recognize the merit in both with the same amount of respect and thought. We no longer suffer disappointment with failure nor do we live with the highs of our success. Instead, we treat both as equal, stay unperturbed and adjust our course as needed.

In the Book of Joy, the Dalai Lama describes "Mental Immunity" which is controlled by our higher level thinking. In Kahneman's idea of fast and slow thinking, he defined systems 1 and 2, and the latter (system 2) can support the Dalai Lama’s idea of mental immunity. System 1 is our automatic, subconscious, intuitive mental state, controlled by our limbic system brain…our “fight or flight” system. Some refer to system 1 as the “lizard brain” and reacts unconsciously to things like threat and other intense emotional states. For example, if you see the tiger, your system 1 will kick in automatically and you’ll react. System 1 is flawed and has many pitfalls in our lives. For example, if you get a nasty email with degrading words from a colleague, system 1 will kick in and we may respond in ways that we may regret later if we don’t override our natural tendencies. In contrast, System 2 makes up our higher level, conscious thought, and is regulated by the prefrontal cortex. In the email example, we may decide to wait 1 day to let the emotions subside so that we can let system 2 think through the best way to respond and ensure we preserve good relationships. Perhaps, we decide to meet the individual in person or talk over the phone instead of an email response to resolve the concerns. The emotional center, our amygdala, is like the traffic control and supports our emotional reactions or responses to events and signals.  We can strengthen the signals and tracks that connect our amygdala to prefrontal cortex (higher level thinking) and limbic system (fight or flight thinking). 

   

The Dalai Lama draws an analogy of physical well-being to mental well-being, and coined the term “mental immunity”. We develop good habits (eating well, exercising, sleeping, etc) to be physically healthy, to boost our physical immunity to fight off colds, sickness and feel good. In the same way, he urges us to develop mental immunity, practicing our mental state to develop and focus on attention and concentration through meditation, so that we can develop mental immunity to struggles we will encounter. The mental immunity refers to system 2, our higher level control center of mindfulness. Activation of system 2 requires focused attention, concentration which ultimately yield mindfulness and awareness. Mindfulness is defined by two components: attention and concentration. When we have mindfulness, we can pause, reign in our intuitive and natural tendencies, and redirect our attention and concentration to the productive path, free of emotional swings. Practicing mindfulness through meditation allows us to strengthen our ability to access and control system 2.

We have different intrinsic ability to control our mental state, system 2, and more importantly we can develop this ability through practice. The famous Stanford Marshmallow test of a bunch of 5 year old kids illustrated our intrinsic ability to control our behavior. Each kid was put into an empty, boring, white, and bland room with a marshmallow on a plate, placed on the table. The rest of the room remains void of toys, or any other attention seeking play things (e.g. iPad). The kids were told to either wait 5 minutes and get 2x marshmallows, or eat 1 marshmallow within 5 min. In a series of hilarious and cute videos (check out YouTube) of little kids doing various maneuvers to delay gratification for a bigger reward (e.g. licking the marshmallow without eating it, and distracting themselves), we see something more profound emerge decades later. The minority of the kids who successfully delayed the 5-min collectively achieved higher level education, higher pay and higher successes than the majority, who failed the marshmallow test, and gave into their system 1 natural tendency to eat the sweet and delicious marshmallow immediately. More importantly, and the key message of the study was the 2nd phase of the study. The research team taught kids mental hacks to help redirect their attention, and practiced these exercises with the kids. In subsequent studies, the kids who received the attention training did significantly better in all the measures compared to their baseline. Nowadays, this study has major implications on the attention of kids growing up with iPads and uncontrolled access to YouTube, where their attention and concentration is drawn to most attention-seeking videos often displaying behaviors that taps into our natural, hard to control tendencies (system 1).

Our ability to control our attention and direct our concentration is the engine that drives our mental well-being. We have baseline levels of control we are born with, and we can cultivate the control through practice. Mindfulness is housed in System 2, and can be easily hijacked by system 1. For example, if something disastrous happens (e.g. our child was in an accident, or fall in love), then we can no longer think coherently and rationally. Our system 2 (higher level thinking) malfunctions due to a tremendous amount of signal from system 1 (lizard brain), suppressing any ability of system 2 to regain control. In the same way, extreme and intense emotional experiences (e.g. anger, depression, love) can make us vulnerable and lead us to make poor choices, say unintended words, entertain terrible thoughts and take regrettable actions. 

Acknowledging this Achilles heel common to all of us, how do we protect ourselves? How do we strengthen system 2 (higher level of thought) and protect it from being hijacked? A simple and easy way is to practice meditation. Meditation consists of putting our attention on a fixed object, and then concentrating on that object over a period of time. A timeless fixed object is our breath. The advantages of the breadth is that it's accessible, and always with us. Others focus on the heart beat, the ticking clock, the feel of the air on your skin, etc. You can also focus on things beyond our senses too, like loving kindness, empathy, compassion. The basic concept is to sit, cross your feet, close your eyes, and set your attention on something (e.g. your breath) and sustain it (concentration). Meditating is like running, remember to keep your expectations appropriate to your level to avoid being discouraged. With time and practice, we can develop our stamina and gain benefits from this exercise. The endurance, speed and stamina will develop over years, not hours. We know meditation works. After 6 weeks of practiced meditation, functional MRI studies demonstrate both increased activity AND volume in important brain centers like the amygdala (our emotional traffic control center).

The benefits of practicing mindfulness are subconscious, and not apparent to conscious mind. When I lift weights, I can feel the muscle pain after a work-out; however, we do not have the same sensory receptors in our brain, so we do not have the same tangible bodily sensation after meditation. I started meditating during residency. I was studying for the radiology boards, and my stress was 11/10. I came across the book, The Art of Learning by Josh Waiskin. His thoughts of performance resonated with me, and I found out that he's a devout meditator. He and other other high performers like Ray Daylio, Steve Jobs, John Lennon, all regularly meditated. Even though Buddha vehemently advocated for us to meditate, the activity in itself is free of religious connotation. I started meditating for 1 minute. Meditation is.the.most.underwhelming activity for a novice. I am accustomed to the feeling of getting things done. Meditation did not give me that rewarding feeling. I guess if you want to know if meditation is working, you can get a functional MRI exam before and over time like the Hopkin group did when they studied the effects of meditation. In addition, meditating is really hard. Keeping my attention on my breath for a period of time took practice. Thoughts, to-do lists, ideas floated into my head. When distraction happens to you, remember that meditation benefits the most distracted minds (that's me, you, and everyone like us). Guided meditation, for example offered through Headspace app, is another way to get into meditation. Headspace is a good app. After a while, I abandoned the app and was able to practice on my own, no longer needing to put the extra steps to find my phone, and turn on the app.

Since starting to meditate about 7 years ago, I can now practice meditation for about 20-30 min everyday. To give you a comparison, the Dalai Lama meditates for 5 hours every day, the first thing in the morning. He wakes up very early (like 3 or 4 am), and meditates till 8 or 9 am (read his Joy book...it's amazing). I've benefited significantly from the positive impact of meditation and would argue the inflection point in my life and career occurred after starting this habit. The slope was gradual and very subtle but over the past 7 years, the trajectory has been striking.

Just as we have different levels of running (5k, 10k, half marathoners, marathoners, ultrathoners, etc), I came to realize there are increasing levels of mindfulness. In Indian and Buddhist traditions, "Samadhi" refers to the highest of the 3 states of self-collectiveness, a luminous mind which is "equanimous and mindful". The first stage is Dharana, being able to hold your attention on an object over long periods of time free of distraction. For example, being able to focus on the breath. The second stage, Dhyanam, occurs when there begins to be a relationship between the mind and the object of attention. You gain insights about yourself from concentrating on the object. For example, by meditating about loving kindness, you gain insights about your ability to process these experiences. The third and final stage is Samadhi. With Samadhi, you and the object become very close, as if they have merged. At that point, the mind sheds its conditioning and the object shines forth as it is. For example, if you meditate about loving kindness in the state of Samadhi, you take on the qualities of loving kindness. At this point, we can see things for what it is (neither good nor bad) and see ourselves for who we are. Ultimately, meditation is about removing our conscious and unconscious biases, and refining our perception like wiping of the dust surrounding a transparent crystal (reference sequencewiz.com).

Regarding Mental Immunity and the pendulum of emotions, what we know is that through practiced mindfulness, we develop our system 2 (self control, emotional regulation, etc), and can develop a mental immunity, of sorts, to the fluctuations of life, and reign in our system 1 (natural, automatic, reactive tendencies). We can narrow the swings of the pendulum a little bit over time and develop our higher order systems (calm ourselves), and rise above these struggles, and recognize them for what they are, rather than become emotionally linked and reacting to them (which we naturally do due to system 1). All of this feels unnatural and takes conscious effort. Eventually, we recognize failures and success as equals, and stay level headed and calm, like the stillness under the surface of the ocean during a thunderstorm. Major struggles no longer cause us emotional harm, and major wins no longer make us elated and high. We remain grounded, at peace, and immune.