Something kept happening on Offcall that we didn’t plan for. Guest after guest, across totally different specialties, kept circling back to the same decision: walking away from employed medicine and building something of their own instead.

This Labor Day, instead of one long conversation, How I Doctor is pulling together the sharpest moments from five of those conversations, physicians in primary care, pediatrics, allergy, and ENT, who each found their own path to independence and never looked back.

Featured in This Episode

• Dr. Farzad Mostashari, Former National Coordinator for Health IT and CEO of Aledade: on the economics behind why independent primary care is making a financial comeback, and why he calls employed physicians "cogs in a machine" built around someone else's goals.
• Dr. Ari Brown, Pediatrician and founder of 411 Pediatrics: on what it takes to stay independent for over thirty years, and her stark warning that independent pediatric practice is now "on the extinction list."
• Dr. Paulius Mui, Family medicine physician and founder of XPC Health: on walking away from full-time employed primary care to build a direct primary care practice where patients pay what they can afford.
• Dr. Basil Kahwash, Allergist/immunologist and co-author of Offcall's Referral Manifesto: on the isolation that comes with independent practice, and his vision for a connected network that fixes it.
• Dr. Bradley Block, Otolaryngologist and board member at ENT and Allergy Associates: on how a 170-partner, full-equity ownership model became too big and too democratic for private equity to buy.

Resources and Where to Find Our Guests

• Dr. Farzad Mostashari's full episode: The Future of Primary Care Is Independence, And It's More Lucrative Than You Think
• Dr. Ari Brown's full episode: What Happened to Trust Between Parents and Pediatricians
• Dr. Paulius Mui's full episode: Reinventing Primary Care to Put Patients First
• Dr. Basil Kahwash's full episode: Going Independent Doesn't Mean Going It Alone
• Dr. Bradley Block's full episode: The Physician-Owned Practice That Private Equity Can't Buy
• Submit a comment on the CMS CY 2027 Physician Fee Schedule (file code CMS-1848-P): regulations.gov
• Read the Referral Manifesto: offcall.com/manifesto
• Learn about Offcall's referral product and new Lounges feature: offcall.com/referrals

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A recent JAMA perspective argued that AI already outperforms physicians in many cases. One emergency physician building an AI health company thinks that argument gets the timeline right and the conclusion wrong.

In this episode of How I Doctor, Offcall co-founder Dr. Graham Walker sits down with Dr. Rishi Khakhkhar, an emergency physician at Mount Sinai and Chief Medical Officer of Counsel Health, an AI-enabled virtual care company. Rishi splits his week between ER shifts and building toward what he calls semi-autonomous care, a deliberate middle stage between fully human and fully automated medicine.

The two start with the patients Rishi sees in the ER who never needed to be there, then work through how AI-assisted, physician-supervised care actually functions in practice: an AI takes a full history first, flags when a physician should join, and leaves the decision to escalate in the patient's hands. From there the conversation turns to the JAMA piece itself, with Rishi agreeing that AI can already outperform physicians on narrow tasks like reading subtle EKGs, while pushing back hard on the idea that human-in-the-loop care is holding medicine back. He compares it to Waymo's years of supervised driving before removing the human behind the wheel, and argues medicine shouldn't rush that same transition.

The conversation closes on what's structurally in the way: a 50-state licensing system built for a pre-internet world, the deskilling risk facing residents who train alongside tools that already outperform them, and what Rishi thinks primary care looks like in 2036, when it may no longer be built around a relationship with one person at all.

What You'll Learn

• How AI-assisted care actually works: what the AI is allowed to decide, and what always escalates to a physician
• Where Rishi agrees and disagrees with the JAMA perspective arguing AI already beats doctors
• Why Rishi resists skipping past human-in-the-loop care
• What Rishi tells residents they still need to learn without AI, and what he thinks doesn't matter as much anymore
• What Rishi thinks primary care looks like by 2036

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Private equity has been buying up ENT and allergy practices at a fast clip. One group has stayed independent and grown into the largest player in its space anyway.

In this episode of How I Doctor, Offcall co-founder Dr. Graham Walker sits down with Dr. Bradley Block, an otolaryngologist and board member at ENT and Allergy Associates, the country's largest ENT, allergy, and audiology practice. Brad is also the voice behind Succeed in Medicine, a physician communication podcast he ran for years and hundreds of episodes before stepping away this spring.

The two start with why Brad built a podcast in the first place, a solo project born out of a long commute and a simple question: how were his partners seeing more patients per hour than he was without sacrificing the visit. From there the conversation turns to ENTA itself, a practice built on a contract every incoming physician can read on day one, one with a clear, no buy-in path to full equity partnership. That structure now spans roughly 170 partners, and Brad makes the case that scale, not resistance, is exactly what keeps private equity away. He also gets specific about what it costs to build a model like this: founding partners who sacrificed financially to create it, then retired with no buyout at all.

The conversation closes on where the real disadvantage lies for independent practices, not efficiency or leadership, but lobbying power on Capitol Hill, where large health systems can outspend independent groups on influencing the reimbursement rules everyone has to live by.

What You'll Learn

• Why Brad built a physician communication podcast because the one he needed didn't exist
• How ENTA's contract guarantees a clear, no buy-in path to full equity partnership for every incoming physician
• Why a 170 partner structure is nearly impossible for private equity to acquire, and why Brad argues it wouldn't even help
• What the founding partners gave up to create the model ENTA runs on today
• The one question Brad tells physicians to ask before joining any practice, and why the leverage to ask it disappears the moment they sign

Resources and Where to Find Brad

• Find Brad on LinkedIn:
• Find Brad's ENTA profile:
• Succeed in Medicine (podcast archive): succeedinmedicine.com
• Find Brad on Instagram and Threads: @succeedinmedicine

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Dr. Ari Brown is a pediatrician in Austin, Texas, who has run her own independent practice, 411 Pediatrics, for more than 13 years and been a pediatrician for more than 30. She's the author of the bestselling Baby 411 series, Baby 411, Toddler 411, and the newly released Expecting 411, books that have sold millions of copies and made her one of the most trusted parent educators in the country. Every new edition means going back and correcting the record, including reversing her own earlier guidance to delay introducing peanuts and eggs once the evidence flipped.

In this episode of How I Doctor, Dr. Graham Walker talks with Ari about what happened to trust between parents and pediatricians, and what it actually takes to hold that trust together while the ground underneath the science keeps shifting. They dig into why vaccines have become victims of their own success, as parents who've never seen measles or chickenpox come to fear the shot more than the disease, and why so many pediatricians have moved onto social media to fight misinformation directly. Ari reframes physicians as teachers first, and walks through the honesty and communication skills she thinks medical training still underserves.

Ari and Graham also get into how instant portal access to labs and imaging has reshaped the emotional weight of practicing medicine, how she coaches families through screens and digital parenting, and what she's seeing families care about most today, from nutrition to developmental milestones. The conversation closes on a warning: with margins this thin, Ari believes independent pediatric practices, and the kind of long-term, trusted care they provide, are genuinely at risk of disappearing.

What You'll Learn

• Why Ari calls vaccines "victims of their own success" and what that means for how parents perceive risk
• Why she believes physicians are teachers first, and what medical training still gets wrong about communication
• How instant portal access to labs and imaging has quietly reshaped physician workload and burnout
• What's actually changed for families in the last decade, from screen time to a growing focus on developmental milestones
• Why Ari believes independent pediatric practice is at real risk of disappearing, and what's at stake if it does

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Dr. Karandeep Singh is a practicing nephrologist, an informaticist, and the inaugural Chief Health AI Officer at UC San Diego Health, where he also leads the Joan and Irwin Jacobs Center for Health Innovation. Back in 2021 at the University of Michigan, he published research questioning Epic's own sepsis model, finding it worked only about 63% of the time and that a clinician might have to evaluate eight separate alerts just to find one real case of sepsis. He's one of the rare people who has been on both sides of AI in medicine, exposing a flawed model and now deciding which ones get deployed at all.

In this episode of How I Doctor, Dr. Graham Walker talks with Karandeep about what it actually takes to govern AI inside a health system, and why the doctors who trust AI the least are often the ones best equipped to run it. Karandeep traces his path from teaching himself to code at age eight, through building tools to solve his own clinical frustrations in training, to formally discovering biomedical informatics as a field only during his nephrology fellowship.

Karandeep and Graham dig into why generative AI feels transformative to physicians while predictive AI often doesn't, even when the data shows it's saving lives. They walk through a real case study of using agentic AI to automate pre-colonoscopy prep calls without cutting nurses out of the loop, and unpack what a Chief Health AI Officer's job actually involves day to day. The conversation closes on Karandeep's case for regulatory sandboxes, structured ways to test AI-enabled care models that current rules don't yet allow, and his prediction for where AI scribes are headed next.

What You'll Learn

• Why Karandeep's research found Epic's sepsis model wasn't doing what its own model card claimed
• Why predictive AI creates work that's hard to feel, while generative AI's time savings are noticeable almost daily
• How UC San Diego Health automated colonoscopy prep calls with AI while keeping nurses at the center of care
• What a Chief Health AI Officer actually does across evaluation, governance, and implementation
• Why Karandeep believes regulatory sandboxes, not blanket approval, are how AI expands access to care

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Dr. Robert Pearl spent 18 years as CEO of The Permanente Medical Group, the nation's largest physician-led medical group, where he oversaw the care of more than 5 million Kaiser Permanente members delivered by 10,000 physicians and 38,000 staff. He's since become one of healthcare's most direct critics from the inside, a Forbes healthcare contributor, a LinkedIn Top Voice, and the author of the Washington Post bestseller "Mistreated" and his newest book, "ChatGPT, MD," which argues generative AI will become as essential to physicians as the stethoscope.

In this episode of How I Doctor, Dr. Graham Walker sits down with Robert, his former CEO, to trace some of the hardest calls of his tenure, including the lunchroom video he made to prepare 10,000 physicians and staff for the uncertainty of the Affordable Care Act. That instinct for delivering an uncomfortable diagnosis before anyone wants to hear it runs through the entire conversation.

Robert doesn't think AI's biggest opportunity in healthcare is cutting physician headcount. He argues the real prize, close to $1.8 trillion by his estimate, is preventing the chronic disease that drives most heart attacks, strokes, and kidney failure before it ever starts.

Graham and Robert get into why fee-for-service quietly rewards a patient staying sick, how hospital consolidation and private equity have monetized medicine in ways unique to the United States, why he believes capitation is the prerequisite for AI to actually work, and what a routine doctor's visit could look like in five years if his vision plays out.

What You'll Learn

• Why Robert says cutting physician jobs is the wrong AI strategy for hospitals
• The real math behind the $1.8 trillion he says is sitting in chronic disease prevention
• Why fee-for-service rewards treating a complication over preventing one
• How capitation changes what a physician group is financially motivated to want for a patient
• What Robert thinks a doctor's visit looks like in five years

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Dr. Jordan Shlain is an internist,= and founder of Private Medical, one of the longest-running concierge practices in the country, and a doctor who has spent 25 years arguing that primary care should never have been bundled into health insurance in the first place. His practice, and his writing on Substack at Don't Listen To Me, have made him one of concierge medicine's most direct voices, direct enough that the New England Journal of Medicine recently devoted a piece to asking whether his model has something to teach the rest of primary care.

In this episode of How I Doctor, Dr. Graham Walker sits down with Jordan to trace the origin story back to when a canceled business meeting sent Jordan wandering into a hotel lobby, where he talked his way into becoming the on-call physician for the Mandarin Oriental. That accidental job became San Francisco On Call Medical Group, then Private Medical in 2002, and eventually a 25-year experiment in what happens when a doctor's incentives and a patient's health point in exactly the same direction.

Jordan doesn't hedge. Insurance, he argues, is a financial hedge against catastrophic loss, not a mechanism for a doctor visit, and folding primary care into that system created most of the dysfunction physicians and patients feel today.

Graham and Jordan get into the actual economics of membership-based primary care, why fee-for-service quietly rewards a patient staying sick, what trust really means when it's stripped down to a promise instead of a marketing term, and why Jordan believes AI will only help physicians if it restores their agency instead of adding another layer of control.

What You'll Learn

• Why Jordan argues insurance was never built for routine primary care
• The real math behind a membership-based practice
• How a flat annual membership changes what a doctor is financially motivated to want for a patient
• The real definition of trust
• Jordan's prediction that 90 percent of healthcare could already move to email, text, and video
• What Jordan would eliminate from healthcare tomorrow if he could

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Dr. David Lortscher is a dermatologist turned founder of Curology, one of the first companies to combine telehealth, prescription skincare, and a subscription model into something patients would actually use. He's also the author of a new book making a data backed case that should unsettle every hospital administrator who's ever doubted a physician founder: Why Doctors Win.

In this episode of How I Doctor, Dr. Graham Walker sits down with David to trace his path from a dermatopathology fellowship waiting for him at UCLA to starting Curology, and then a decade later stepping back from the CEO seat. That gave him time to go looking for proof that his own success wasn't a fluke.

What he found is that 51 of the top 100 healthcare companies founded in the last 40 years had a physician founder!

Graham and David get into why the doctor plus engineer pairing keeps showing up in the biggest healthcare success stories, the blind spot that trips up even smart physician founders, and David's blunt rule for anyone gathering advice before making the leap: take the inputs, not the conclusions.

What You'll Learn

• Why physician founded healthcare companies outperform at roughly 3x the rate you'd expect from their overall representation among founders
• The doctor plus engineer combination that shows up in 7 of the 10 companies profiled in Why Doctors Win, and why it works
• How an MD behind your name changes the way you sell into a hospital, from the CMO's office up to the CEO and CFO
• The most common blind spot physician founders hit: falling for the technology itself instead of the harder question of who will actually pay for it
• David's rule for gathering advice from as many people as possible while still keeping the final decision your own

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Dr. Brian Anderson is a pediatrician turned CEO of the Coalition for Health AI (CHAI), the organization behind the push to give every AI tool in your EHR something like a nutrition label: what it was trained on, who trained it, and where it might fail.

In this episode of How I Doctor, Dr. Graham Walker sits down with Brian to trace his path from a Mass General exam room, where a clunky EHR rollout first pushed him toward building technology instead of just using it, to running a coalition of more than 3,000 organizations trying to agree on one deceptively hard question: what does good AI in healthcare actually look like.

They also break two major pieces of news together, live on the show. OpenAI and Anthropic are donating thousands of AI licenses to public health agencies through CHAI, aimed at rebuilding trust in digital tools after decades of underinvestment. And CHAI is launching a health sector specific version of Anthropic's Project Glasswing, bringing serious cybersecurity firepower to the industry Brian calls the most attacked critical infrastructure in the country.

Graham and Brian also get into what "human in the loop" should really mean for a working physician, why model cards solve procurement but not the fifteen-minute exam room, and what CHAI is doing to finally connect AI performance to real clinical outcomes.

What You'll Learn

• What CHAI's model cards actually tell a physician, and the gap that still exists between hospital procurement and the exam room
• The details of CHAI's new partnership with OpenAI and Anthropic, and what it means for public health agencies gaining free access to Claude and ChatGPT
• Why CHAI is bringing a health sector version of Anthropic's Project Glasswing to hospitals, the most attacked critical infrastructure sector in the country
• How CHAI plans to measure whether AI tools are actually improving patient outcomes, not just getting deployed

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A few weeks ago, Graham sat down with Dr. Wendy Dean, co-founder of Moral Injury in Healthcare, for one of his favorite conversations this show has ever recorded. It's the kind of episode that changes how you talk about your own job.

That's why this week, How I Doctor is doing something new: handing the feed over to Wendy's own show, 43cc, which she co-hosts with orthopedic surgeon Dr. Matt Ramsey. 43cc bills itself as informal, informative, and irreverent, and if this episode is representative, that's undersold. It's the conversation you'd have with a colleague after a brutal clinic day, if you let yourself say the quiet part out loud.

In this episode, Wendy and Matt start from a real patient encounter, a $3,100 out-of-pocket shoulder MRI on a $6,500 deductible, and use it to walk through exactly how the system got this expensive and this hard to fix from the inside. They don't stop at diagnosing the problem. They name the specific legislative mechanism (a provision buried in the Affordable Care Act) that keeps physicians from building an alternative, and the bills currently in Congress trying to undo it.

What You'll Learn in This Episode:

• Why one patient's $3,100 out of pocket MRI charge reveals exactly how high deductible plans are designed to work against patients, not for them
• The real difference between concierge medicine and direct primary care, and why Wendy argues only one of them actually changes the underlying cost of care
• How Section 6001 of the Affordable Care Act froze the growth of physician owned hospitals in 2010, and why reversing it has become one of the more promising paths to real competition in healthcare
• Why employer sponsored health plans, not federal legislation, may be the most realistic lever for forcing change in how insurers and hospitals operate

Subscribe to 43cc wherever you get your podcasts to hear more from Wendy Dean and Matt Ramsey. Full episode and show notes here: 43ccpodcast.com

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