Show Notes
The National Institute on Drug Abuse defines addiction as a "chronic disease" occurring in the brain – Many believe this definition can help to reduce stigma. But, is it helpful in the care of individual patients? In this episode we discuss what we gain and what we lose when we speak of people with addiction as having "diseased brains." The view of addiction as a chronic disease has traction, supported first by mid 20th-century alcoholism research, and then by a flood of brain imaging and neurophysiologic studies. Functional MRIs highlight changes in the brain, whether the addiction is to a substance like alcohol or opioids, or to a behavior such as gambling or disordered eating. Many authorities suggest that the "brain disease" designation is not only correct on scientific grounds, but that it also advances a social priority: to blunt stigmatizing concepts of addiction as a weakness or moral failing. However, many neuroscientists disagree with the brain disease model. Without disputing the brain science, they note that all learned behaviors change the brain, not just addiction. Also, people who reduce or stop use often report they chose to make that change because of new opportunities or intolerable consequences. The brain disease argument invites a second criticism: arguably, it lets unfettered capitalism off the hook – predatory industries spend billions to get people addicted. Calling it a disease of an organ conveniently focuses attention away from a predatory system. Why does this debate matter for clinicians and patients? Saul interviews co-host, Stefan Kertesz, who is a primary care doctor and a board-certified addiction medicine specialist. Together we consider how addiction is a part of the human condition, which includes how we learn, how we relate to the environment in which we live, and how we are shaped by experiences. Nearly everyone has habits that are problematic to varying degrees. How we think about addiction can shape our approach to patient care across a wide range of clinical interactions.
More from On Becoming a Healer
As On Becoming a Healer begins its seventh year, Stefan turns the questions on Saul: What does it actually mean to "become a healer"—and why does that idea remain at the center of both the podcast and Saul's 2020 book, On Becoming a Healer: The Journey from Patient Care to Caring About Your Patients? Beginning with an encounter in which a patient's worsening back pain could not be understood apart from a devastating recent trauma, Stefan and Saul explore the difference between treating a clinical problem and engaging with the person experiencing it. They consider why genuine engagement is not friendship, forced intimacy, "good bedside manner," or additional emotional labor; how boundary clarity makes openness safer; and why medical education has such difficulty teaching something that cannot be reduced to a script or competency. In a profession increasingly shaped by financialization, bureaucracy, and the efficient-task-completer mindset, it is not enough to ask what physicians are against. We must also ask what they are for. This episode argues that engagement is not an optional grace note in medical care. It is medicine's missing center—and the foundation of a healing interaction.
What happens when a healthcare system organized around profit repeatedly gets in the way of doing what is right for patients? Physicians for a National Health Program (PNHP) calls one consequence moral injury: the distress physicians experience when the system prevents them from providing the care they believe patients need. PNHP president Diljeet Singh, MD, DrPH, joins Stefan and Saul to discuss the organization's recent report on moral injury and the financialization of American medicine. Saul strongly shares PNHP's commitment to universal health care—but challenges whether the language of moral injury puts too much emphasis on what the system does to physicians and too little on physicians' own agency and responsibility within that system. What follows is a candid and provocative exchange that begins with substantial agreement about what is wrong with American health care and the need for universal coverage, but moves into harder questions about moral distress, physician complicity, professional responsibility—and how much courage we should expect from doctors when doing the right thing comes at a personal cost.
Fazlur Rahman, a retired oncologist, is the author of The Temple Road, a richly evocative memoir about growing up in what was then East Pakistan, before it became Bangladesh. His second book, Our Connected Lives, chronicles several patients he cared for during his 35 years as a cancer doctor in West Texas – and his relationships with them in the rural region where he was the only oncologist. Fazlur is a gifted writer who became a beloved physician in a community that needed him. Fazlur also faced prejudice along the way, and his story is a reminder of how much America gains from those who come from seemingly far-off lands. It is an inspiration and illustration of humility, presence, compassion and joy in patient care.
Most of us who care for patients can remember seeing a name on the schedule and feeling our heart sink. What makes some clinical relationships so difficult? Is it something about the patient—or something about the interaction itself? Dr Jeffrey Jackson has spent more than two decades studying this question. His research has shown that difficult encounters are associated not only with patient characteristics but also with physician factors, including the clinician's approach to psychosocial issues. In this conversation, we explore what his work can teach us about why encounters become difficult, how trust can gradually emerge, and why some of the patients that physicians initially dread eventually become among the most meaningful to care for. Along the way, we discuss chronic pain, personality disorders, longitudinal relationships in primary care, the role of physician self-awareness, and the difference between caring for patients and trying to control them. This episode asks what it means to remain present with patients whose suffering—and whose behavior—challenge us the most.
Over the past several years, contextualizing care has surfaced repeatedly on On Becoming a Healer. In 2025, contextualizing care was incorporated into new Foundational Competencies for Undergraduate Medical Education. Around the same time, co-host Saul Weiner worked with the Institute for Healthcare Improvement (IHI) to develop an online course designed to teach these skills, called Contextualizing Care for the Clinician (IHI Open School). Now that the course has been added to IHI's subscription-based Open School curriculum, making it available to learners at hundreds of subscribing institutions, we thought it would be a good time to revisit several conversations from past episodes that illustrate what contextualizing care is, why it matters, and how we can teach it.