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When I was a boy, I watched a PBS NOVA episode with my parents about a woman who was sick in the hospital, and no one on her treating team could figure out what was wrong with her. In the end they had to bring in the neurosurgeons to biopsy her brain, and the diagnosis turned out to be a form of encephalitis. I remember being surprised that something could go wrong with the brain in a way that made it so hard to diagnose. That surprise stayed with me for years before I knew what to do with it.
The Night My Brother Was Hurt
In my second year of college I was a music major. I studied classical trombone, and I helped pay my way by playing in a salsa band in the Miami Latin music scene. I had been at a gig the night my mother called my dorm room to tell me my brother had been in a car accident.
I went straight to the emergency room at Baptist Hospital in Miami. He had a traumatic brain injury, with blood collecting around his brain and putting pressure on it, and he needed surgery to drain it. I remember seeing blood coming from his right ear, and I remember feeling an immediate urge to take care of him. One of the first things I said to my mother was that his contact lenses needed to come out, because his eyes looked so dry and uncomfortable.
When they wheeled him through the operating room doors, my mother collapsed and my father was badly shaken. I have thought about their reactions many times since then, standing with the families of my own patients. Much of how I talk with families today comes from that night.
What the System Could Not Do
My brother's surgery went well, and he was discharged about a week later. His neurosurgeon, Dr. Raul Rivet, gave him outstanding follow-up care. But in the weeks and months after, it became clear that surgery was only the beginning of his healing. His mood was unpredictable, some of his abilities had changed, and an injury like his can take away part of the insight a person needs to see those changes in himself.
What he needed was a team around him: a nurse, a psychologist, a therapist, and educational support. My mother was a nurse and an excellent researcher, and even she found it hard to pull those pieces together. If it was that difficult for her, I could only imagine what it was like for a family without her training. That was the first time I understood how poorly our healthcare system serves people with brain injuries and the families who care for them.
That experience changed my course. My mother gave me a copy of Oliver Sacks's The Man Who Mistook His Wife for a Hat, and after talking it over with my family and friends, I switched to pre-med. I had about two years of prerequisites to make up, so I took 15 to 18 credit hours every semester, summers included, until I had caught up.
Choosing Neurology When My Classmates Said Not To
In medical school I was tempted by other fields, but I kept coming back to the neurosciences. A number of my classmates thought I was wasting my time and told me I should become a cardiovascular surgeon or a plastic surgeon. At the time, neurology had very little to offer in the way of treatment. Therapies for multiple sclerosis were just getting started, and there was practically nothing available for Alzheimer's disease.
I saw that gap as the reason to go into the field rather than a reason to avoid it. During my clinical rotations at Tampa General Hospital, the hospital was planning a neurological intensive care unit, and I was following the acute stroke trials closely. I believed new therapies were coming, and that neurology would eventually lead medicine rather than follow it. It was a lonely choice at first. For a long time our idea of health, and much of our economy, has been organized around the heart and the body. I believed then, and believe more strongly now, that the brain is becoming the center of it, which is the idea behind what I call the Neuroeconomy.
The Patient Who Changed My Training
My family has its own history with stroke. My father's mother died of a massive stroke in her 40s, when he was only 13, and he spoke about it with deep sadness for the rest of his life. In her time, there was nothing a doctor could have done to reverse it.
In 1995, the National Institute of Neurological Disorders and Stroke tPA trial, published in the New England Journal of Medicine, showed that the clot-dissolving drug tPA improved outcomes for patients treated within three hours of stroke onset. The FDA approved it for stroke in 1996. I was in my first year of neurology residency when a woman arrived within that three-hour window and met every criterion for treatment. We had very little time to decide. I ordered tPA, and I watched her deficits reverse completely in front of me.
I was almost fired on the spot, because our department had not yet built the protocols or settled the chain of command for that decision. I learned a great deal about the politics of medicine that day, and I also learned that I wanted to spend my career intervening rather than observing. My academic advisor, Dr. Shashi Kori, introduced me to Dr. Camilo Gomez, who was one of the few physicians in the country treating stroke that aggressively, and Dr. Kori generously allowed me to spend a month training with Dr. Gomez. I went on to complete a fellowship under Dr. Gomez in stroke, neurocritical care and neuroendovascular therapy from 1999 to 2001, and then stayed on the faculty at the University of Alabama at Birmingham for another two years. That work was some of the most difficult and most rewarding of my life, and I still hold him very dear.
Building a Career Inside the System, and Losing It
After training I was recruited by a large multi-hospital system in Jacksonville, Florida, where we developed a comprehensive stroke center. That work attracted a local neurosurgery group to join the hospital, and our Neurology and Neurosurgery program was later ranked by U.S. News & World Report among the top 50 in the country. I eventually became chief of neurology for the system.
Over those years I also saw how limited our hospital systems are in some very important ways. The pressure to reduce the quality of care kept growing, and I came to believe it was harming patients. After seeing repeated cases of neglect, I reported my concerns to the Florida Agency for Health Care Administration, because I could no longer stay silent without being complicit. That decision cost me my position, my place in that health system, and nearly everything I owned. For about seven years, while the legal cases worked their way through the courts, I was disillusioned and unsure what came next.
Why I Came Back
In 2018 I recommitted to the practice of medicine and opened the clinic that became The Neurogenesis Project. I came back because former patients reached out to me. They were frustrated that they could not find anyone who took care of them the way I had, and some of them told me they had always seen me as a scapegoat. That gave me the confidence to build again.
I built the practice on a direct-care model on purpose. The health insurance industry and the industrial hospital system were at the root of the conflicts I had lived through, and I did not want to rebuild inside them. Direct care allows me to spend as much time and energy with each patient as their condition requires, without the overhead of a conventional clinic.
It also allows me to give families what my mother never had. When a patient comes to us with a brain injury, a neurodegenerative condition or another complex neurological problem, we serve as their medical home. We convene trusted referral partners in the community, conference around the patient, and work with an intensity and cadence meant to accelerate healing. We give families educational material and connect them with support organizations, so that no one has to assemble the team alone. That approach is the foundation of our Intensive Brain Health Program.
Where This Work Is Going
Over the next ten years, my goal is to refine our protocols and care model to the point where they can be offered across the country, and to use AI so that patients can receive our care virtually, through health agents and neurocoaches we train ourselves. I want us to make real progress against neurodegenerative disease, stroke, neuroinflammatory disorders and ME/CFS. And I hope the idea of the Neuroeconomy helps build a movement toward brain health optimization, so that caring for the brain becomes as ordinary as caring for the heart.
I became a neurologist because of the curiosity that was instilled in me as a child, the personal family impact of brain disease, and a mother who struggled to find the help her son needed. If you or someone you love is facing a neurological problem and you feel like the only one holding the team together, we would welcome the chance to talk with you. You can read more about our clinical team on our About page.
This article was drafted with the assistance of AI writing tools, then reviewed, edited, and approved by Dr. Sean C. Orr, M.D., who holds full editorial responsibility for its content.
Source: The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581-1587. doi:10.1056/NEJM199512143332401.