Seeing the world through incentive eyes.
No longer looking away has been the trial of my life.
I came across a vlog a few weeks ago. A man sitting alone in the mountains, telling the story of how he got there. He goes by Dr. Goobie - not his real name, and I’ll come back to why that matters - and his account is this: an MIT-educated neurosurgeon who practiced for nearly a decade, took the oath, did the training, performed the surgeries, and slowly discovered that what he was doing wasn’t healing people the way his training promised it would. So he quit. No plan. Just out.
The video has nineteen million views.
I recommend watching it end to end. Not because every claim in it is verified - he’s anonymous, and his particulars can’t be independently checked - but because of what you can see in his eyes while he talks. I know that look. It’s the look of a man who saw the machine clearly and could not unsee it.
That same look is burned into my retinas in a way I don’t know will ever fully resolve.
I call them my incentive eyes.
The claim worth taking seriously
Strip away the virality and his testimony contains one very specific, very falsifiable claim about modern American healthcare:
If you are a physician who believes in a conservative approach to care - one that does not create a billable service line for the system - you are going to be a physician who has a very difficult time finding a job.
A physician can be sincere, well-trained, and oath-bound, and still find that the only viable seats at the table are the ones that generate charges. Nobody has to be the villain for the outcome to be poor.
I should tell you that other surgeons pushed back on him, publicly and hard. That criticism deserves to be heard, and parts of it may be fair. Outcomes vary. Burnout distorts. One anonymous testimony proves nothing by itself.
I’ve worked with spine surgeons in particular for quite a long time. Put ten of them in the same room looking at the same imaging and clinical context - you are going to see lively debate. That is the human part of healthcare that I love.
While the testimony proves nothing in a silo, I can add some perspective.
The other chair
I sat in the other chair.
He watched the system from inside the surgical suite. I watched it from the machinery around the suite - a career spanning clinic operations, insurance, device distribution, administration. Expert-level production the whole way. Top performer everywhere I went. I was good at the work, and for a long time I told myself that being good at it was the same thing as it being good.
Over time, the compass began to blur in ways I could not describe to the people around me. I watched incentives, domain by domain, and domain by domain the same answer came back: the system was not optimizing for the patient. I was an operator in some systems that I look back on with profound regret. It was because I was compliant. For the money.
And I shouldn’t have been.
He named the physician-side symptom: conservative care can’t find a job. I can name the operator-side mechanism: every domain I worked in was compensated on volume, throughput, and billable events, and none of them were compensated on the patient quietly getting better without us.
What it costs to see
There is a reason his video hit me the way it did, and it isn’t the healthcare argument. I can make that argument on my own (and I am).
It’s the pain in his eyes. Whatever you conclude about his claims, the cost of saying them out loud was real - and I don’t mean financially. I mean the specific, hard-to-describe cost of standing in front of the world and admitting that the work you were trained for, the work you were good at, was not what you believed it was. Being honest is hard. It is much harder when honesty indicts your own résumé first.
I know that cost because I’m paying it. I was not a bystander to the incentive structures I describe. I was a working part of them.
But here is what I’ve learned about that trade: the sight doesn’t go away, and neither does the debt. Once the incentive eyes open, you can either spend the rest of your life pretending they didn’t, or you can put them to work.
The clock
For me, the deciding factor wasn’t philosophical. It was cardiac.
After years of arrhythmia - six ablations, a decade of load - my rhythm finally quieted, and when the never-ending stress signaling took a breather, I was completely lost about what to do with my life. What I knew was narrow and absolute: it could not be wasted continuing the path I was on. And I knew the matter carried urgency, because if things cascade with my heart again, I was not going to leave this world with the words I am sorry being the last thing I say.
He went to the mountains. I went to the build. He says in his video that there are infinite ways up the mountain and only one peak - that we’re all trying to get to the same place, and it’s okay to take different paths.
He’s right. His path out was rest. Mine is work. Relentless work.
Different paths. Same peak: a healthcare system where seeing clearly doesn’t cost this much, and where the patient’s quiet recovery is finally somebody’s business model.
Watch his testimony. Then decide what your chair has shown you.
— Matthew J. Adams
ad astra per aspera
Know your why. Bear the how.