Offcall Physician Spotlight: Meet Dr. Nicholas Melucci

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1. Nicholas, what's one task you've fully handed off to AI that you'd never take back? Two, and they live on opposite ends of my day: On the non-clinical side, it's the scaffolding of anything long-form or open-ended. Big writing projects, planning out my fellowship search, even outlining research ideas and figuring out which ones are worth chasing. It's turned projects I'd have abandoned into things I actually finished.

Clinically, it's first-pass clinical questions on shift. I'll use something like Doximity Ask to quickly get oriented on a dosing question, an interaction, a workup nuance I half-remember, the kind of thing I'd otherwise burn ten minutes chasing.

2. Are you worried about deskilling — that the next generation won't develop the intuition you did because the model handled it? Yes and no. I'm less worried about AI handling the task than about it handling the learning/reasoning behind information. A lot of EM intuition is built in the moments where you're uncomfortable, uncertain, and forced to commit anyway. If a tool smooths that over before an intern ever sits in the discomfort, they don't get the reps. That said, every generation says this. My attendings learned certain skills that are already obsolete with technologies created before I started residency. My real worry is subtler: that we'll lose the ability to catch AI hallucinations when they’re confidently wrong, because you only catch these answers if you know the answer well yourself.

3. If you could redesign residency from scratch, what's the first thing you'd change? I'd treat the schedule as the safety issue it is rather than a rite of passage. The hardest parts of residency teach us despite the exhaustion, and I don't think the brutality itself is what makes us good.

I come at this from an athletics background, which is part of why it stands out to me. Sport learned decades ago that planned recovery and focused, varied reps outperform constant maximal effort. Elite performance isn't built by grinding athletes into the ground every day. It's built on periodization, deliberate recovery, sleep, and attention to the mental side of performance. We have a real science of how to sustain high performance in a human being, and I'd love to see us apply more of it to the people we ask to make life-and-death decisions at hour twenty.

What draws me to this isn't a critique of the people who trained before me. They did extraordinary work under the rules they were given, and I have enormous respect for it. It's that the evidence on sleep, error rates, and burnout has matured a lot, and I think the next iteration of training can fold that evidence in without losing the rigor that makes EM what it is. Society applies this same evidence to numerous high performance fields. I'd like us to extend a little more of it to ourselves, in a way that keeps us sharp for the full length of a career rather than just the length of a residency.

4. Independent practice in 2026 — endangered species or quiet comeback? Endangered. The consolidation in EM, the rise of large staffing groups and private-equity ownership, was a deliberate financial strategy, not a market accident, and it has real consequences for how independently any of us can practice. There's a small but real comeback in some specialties where physicians are deliberately rebuilding independent models, but for most of us entering attendinghood now, "independent" describes a way of practicing more than an employment status. You can hold onto real clinical independence inside a system that owns the contract, and plenty of excellent physicians do. The open question is how durable that independence is as ownership structures keep changing.

5. What's something physicians are quietly worried about that the public doesn't know about yet? How much of a broken social contract emergency medicine is quietly holding together, and how close that's getting to its limit.

The public sees a busy ER and assumes the system is straining but holding. What we see is that boarding, meaning admitted patients with nowhere to go, has gone from the exception to the norm. We've become the pressure-release valve for a system running over capacity for years, absorbing every failure that happens upstream and downstream of us.

That strain is starting to surface publicly, including the violence against staff that has become a routine part of the shift, and shows like The Pitt are putting it in front of people. But it raises a question I think we owe ourselves across every generation in this field. We come from a tradition of sacrifice, and that ethic is one of the best things about medicine. The danger is when sacrifice becomes the system's plan rather than the exception. The answer isn't to care less; it's to stop building a system that depends on our selflessness to keep it standing, especially as a wave of physicians near retirement and others leave the field far earlier than they intended. The demand on the backstop keeps climbing while the number of people able to be that backstop shrinks. How do we honor what this profession has always stood for while building something the next generation can sustain?

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