Hey me! This is a little bit different than what I've been doing for the last few weeks, but here is me journaling as I go on a walk outside of my work again. I’ve slept really well the last three nights in a row and I’ve been able to exercise pretty well, and I have had a pretty good amount of social interaction. I’ve also been eating relatively well, and so it kind of sucks that I don’t necessarily feel the greatest. I don’t think I would say that I’m depressed right now but it is a little bit adjacent to that. There’s a very small dull pain in my chest but it’s enough to make it where it feels like I am slightly less than neutral meaning I have a little bit of that anxiety of this feeling not going away.

Going on a walk specifically on this route reminds me a lot of when I first went through my break up and additionally I also saw a Mazda which was something that reminded me of her. Thankfully time does heal a lot, as I don’t really think of her much anymore, and when she does pop up in someway or another it’s something that doesn’t hurt and I can acknowledge the thought goes away just as quick as it came. And I am happy that I feel like I found a friend group that I can text and do stuff with, but then I feel a little bit scared about the fact that I have done the things and filled the niches I thought I was missing and here I am still not necessarily content with my life. And I think the scary part is losing what seems like a solution or control over a problem, and realizing that it’s not that simple.

One of the things that comes to mind if I try to triage what is causing this could be my relationship status. And I will say that I am very grateful that it feels like I’m a different person and I have grown because I have had essentially two relationship prospects that I am content to walk away from because I can recognize that there are certain things that matter to me very much. Especially communication and conflict resolution. I’m very happy that I have started to read the book nonviolent communication because I think that really did help me recognize things I wasn’t aware of before. I did pride myself on communication before and now this only makes it so much better. And additionally I do think that communication is a skill that is severely neglected, and often is the thing that is now a dealbreaker to me. And I remember that an earlier version of myself viewed the problem as a certain emotional skills are something that are very rare, and so the optimization objective is finding someone on the higher ends of the distribution. I think currently it has shifted more to something like finding someone that meets my criteria, regardless of how many people will reach that or how reasonable even that is. And I think the fundamental change that has enabled this is the fact that outside of sex and maybe physical intimacy, I am able to satisfy all of my other niches in life. Meaning I don’t need a partner and because of that I am completely content with the possibility of not having a partner for the foreseeable future. And I know that it is a very cliché thing to say that, but I think in the past I have said that I don’t need a partner but that means that I really do want one though. It’s like saying that I don’t need a car to get to work because I could always walk for four hours, but I very much want a car. But right now I don’t feel like I have any of those heavily burning wants, especially proven by the fact that the current relationship prospects I am content not pursuing them. One thing my therapist pointed out with how one of the people is essentially a much better fit and overall healthier partner than E was, but even with that and knowing that if I was to engage in the relationship it would be essentially better than my last one, I still do not want to pursue it. To me I think that that is a very solid signal for growth, and I’m very proud of myself for that. And I think the thing that I’m very proud of is the fact that this is not a conscious decision that I have to make but rather something where I understand that this person is not at all a bad person, and there are a lot of very admirable qualities about her, but there also are certain things that I don’t see them that I would like to see in my lifelong partner. Like it is a very important thing to me that my partner is able to handle criticisms and take accountability without excuses or defenses, but rather with empathy and curiosity. And I don’t think that this is at all common and it’s a very rare thing, and it’s not that someone is a bad person or shitty communicator if they don’t do those things, but for me I think I’ve learned that that is something that I really really value and for my specific childhood that makes it matter so much more. And I think that I am really growing to fill the cracks at my childhood left me with. And that is something I’m very grateful for.

Rangers vs Athletics

My MLB game of choice this afternoon has my Texas Rangers playing the Oakland Athletics, the opening pitch is only minutes away, and I'm tuned into the Texas Rangers Radio Network for the call of the game.

And the adventure continues.

No, ladies and gentlemen. Nothing happened today. Consistent. Quiet. Try to contain your disappointment.

I’m starting to understand why people panic when nothing happens. They need something to chase, someone to miss, something to label as “love” so the silence doesn’t start sounding too honest.

I don’t.

There’s no urge to romanticize anything. No interest in whatever people keep advertising as “connection.” From a distance, it all blends. recycled lines, rehearsed emotions, temporary attachments, desperately trying to look permanent. Convincing, if you don’t look too closely.

Sex, love, whatever sits in between, it all ends up in the same category: unnecessary. Somewhere along the way, it just… stopped mattering. No dramatic speech, no cinematic realization. It faded. Quietly. Until there was nothing left worth noticing.

Efficient, honestly.

There’s probably a word for it. Not “heartless.” That would suggest something was taken. More like uninterested. Permanently.

I don’t care about being loved. Don’t look for it. Don’t miss it. It barely exists unless someone else insists on bringing it up like it’s breaking news.

Strange.

Stranger, when you remember, I wasn’t always like this. I used to put effort into it, say the right things, mean them, even go as far as romanticizing details that didn’t deserve it.

“Impressive, in hindsight. Almost convincing.

If someone/ something from before comes back, I “turn into someone different” again. Yeah. Love gets reinstalled like it was never deleted. Very reliable system, Suddenly it’s all meaningful, cinematic nonsense again. Sure. Or it’s just the same thing it was before, just with better excuses this time. Either way, doesn’t really move me. I don’t think about it

Right now, this version is easier. More accurate. I function better without all that “Loveee” people are so committed to. No unnecessary expectations. No disappointments, no need to perform emotions on cue. “Very inconvenient, I know.” -

People call that “empty.” They can call it whatever helps them sleep at night. Labels tend to comfort the confused.

Nothing happened today, Nothing was missing either.

Tragic, isn’t it.

Sincerely, Ahmed

P.S. If you’re expecting love letters or poetry, you’re looking at the wrong person. That version of me got erased. No refund. But if I ever do, congratulations, it won’t last long enough to matter.

Abre la ventana para mirar a la gente de otro modo: pequeña, colorida.

It’s a time to be, and a time to share. To give a piece of yourself to your purpose. On this path, you must therefore let go of people and things that do not align with that purpose.

“Not all [blank]…,” he said.

You are in service of others. You feel and think deeply for others. If you cannot feel deeply about someone in your midst and that you cannot envision them as part of your purpose… then why venture forth. It’s time to say goodbye. It’s time to go.

“What do you secretly wish for?

Perhaps, this isn’t a question for me, but for him.

Hasta bajo techo, llueve. Somos un lago que se evapora. Rocío.

10年ほど前から腰の不調があり、デスクワークがほとんどできなくなっていた。 痛いというよりは、むしろ気持ち悪い。 腰から来る不快感のようなもので、常に吐き気に近い感覚があった。

この、なんとなく気持ち悪いという感覚を医者に伝えても、うまく取り合ってもらえない。 感覚的な表現でしか説明できないものは、専門的に言語化されていないと理解されにくい。

会社の上司などを見ていても感じるが、努力不足だったり、正しい言語に正規化しないまま言葉を渡したりする事に対してやたら厳しい人がいる。 自分で努力するべきだ、という価値観を無自覚に押し付けてくる。 そして、その押し付けすら気づいていないように見える。

だから世の中は少し生きづらい。 感覚的なものをそのまま受け取ろうとしない人が富裕層に多すぎる。 結局、そういう人たちが作ったルールに従わざるを得ない。 中には甘えるなと言ってくる人もいる始末。

まあいい。

とにかく、腰がずっとつらかった。 回したり、ほぐしたりを繰り返しているうちに、ある時ふと腰の違和感が消えた。 しかし今度は、お尻や太ももに同じような気持ち悪さが出てきた。 やはり痛みではなく、不快感だ。

特に左側。 左の太ももあたりをほぐしていると、今度は左の脇に詰まるような感覚が出てくる。 左腕を横に伸ばすとどこかで引っかかる。 ただ不快なだけで、原因の場所が特定できない。

そんなことを繰り返しながら、たまに普段しない動きをしたときに、偶然その原因に当たることがある。 その時は、そこを重点的にほぐす。

昨日はお尻の下に硬さを見つけて、そこを退治した。 ただ、まだ脇の詰まりと首まわりの違和感は残っている。

良い整体師の見つけ方も分からない。 自分にとってまだこの世界はまだ全然優しくない。

3.45 Ripon Yorkshire’s Garden Racecourse kicks off it’s 2026 season today and in 3.45, Tim Easterby has won the race twice since 2019. His MISTER SOX seems to have a really solid each way chance here ticking plenty of boxes; 7/2/4p at the course, goes well fresh, ground and trip ideal, 4/2/3p in April and is 16/6/10p on an undulating course like Ripon. From what I can make out there should be plenty of pace for him to aim at and he should find this easier than recent assignments. The only real negative is his mark which ideally could do with being a couple of pounds lower, but he was half a length third off the same 79 he goes off today on his last run at the track in a class 2. Should be really competitive here.

MISTER SOX // 0.5pt E/W @ 17/2 5 places (Bet365) BOG

I also looked at the last race at Ripon and I couldn’t split the Harriet Bethell trained pair of Milteye and On The River here, as both have good chances. I’d also have given the old boy Garden Oasis, an each way chance here if it hadn’t been for the recent rain, but that has put me off. So just a watching brief in the race for me.

Ledger.com/start – Your Complete Guide to Setting Up a Ledger Wallet Securely

What is Ledger.com/start?

Ledger.com/start is the official onboarding page provided by Ledger to help users safely set up their hardware wallets. Whether you're new to cryptocurrency or an experienced investor, this page ensures you follow the correct steps to protect your digital assets from theft, scams, and unauthorized access.

Using Ledger’s official setup process is crucial because it minimizes the risk of phishing attacks and ensures your device is genuine and uncompromised.

Why You Should Use Ledger.com/start

Setting up your crypto wallet through Ledger.com/start offers several advantages:

Official and secure setup instructions Protection against counterfeit devices Step-by-step guidance for beginners Direct access to Ledger Live software Enhanced asset security with hardware encryption

Skipping the official setup process can expose your funds to serious risks, so it’s always recommended to start here.

Step-by-Step Guide to Get Started 1. Visit Ledger.com/start

Go to the official setup page using your browser. Make sure the URL is correct to avoid phishing websites.

1. Choose Your Ledger Device

Select your device model (such as Ledger Nano S Plus or Ledger Nano X) to receive tailored instructions.

1. Download Ledger Live

Install Ledger Live, the official application used to manage your crypto assets, check balances, and install apps.

1. Initialize Your Device Set up a secure PIN code Generate your recovery phrase Confirm your recovery phrase carefully

⚠️ Never share your recovery phrase with anyone.

1. Add Crypto Accounts

Once your wallet is set up, you can add different cryptocurrency accounts and start managing your assets securely.

Key Security Tips for Ledger Users Always access the setup via Ledger.com/start Never enter your recovery phrase on any website Verify device authenticity during setup Keep your recovery phrase offline and safe Avoid third-party setup guides that ask for sensitive information Common Issues and How to Fix Them

Device not connecting? Try switching USB ports or using a different cable.

Ledger Live not installing? Ensure your system meets the minimum requirements and download only from the official source.

Forgot PIN? You can reset the device, but you’ll need your recovery phrase to restore access.

Benefits of Using a Ledger Hardware Wallet Offline storage (cold wallet security) Protection from malware and hackers Support for multiple cryptocurrencies Easy-to-use interface with Ledger Live Industry-leading encryption technology Final Thoughts

Using Ledger.com/start is the safest way to begin your journey with a Ledger hardware wallet. By following the official instructions, you ensure your crypto assets remain secure and under your control.

For years I've been seeing mentions of Margaret St. Clair's Sign of the Labrys and The Shadow People. Both appear in the “Appendix N: Inspirational and Educational Reading” of the Dungeon Master's Guide, and both are relatively obscure. I was always attracted to their covers, but was unable to just walk to the local library and borrow them.

Something had gotten into me yesterday, and I decided to hunt both down—in their ebook form. I am quite confident there was nothing special in the print version, besides beautiful covers that is, since they were plain small-sized paperback.

Few hours later, and I procured Sign of the Labrys (1963), The Dolphins of Altair (1967), The Shadow People (1969), and The Dancers of Noyo (1973) novels. According to St. Clair's Wikipedia page, the last three form some sort of loose trilogy. Their ebook covers are quite underwhelming so I downloaded the originals from the web instead.

I opened the Sign of the Labrys, “just to check it out,” read first few paragraphs, and realised I couldn't just put it down. I finished it in a couple of hours.

Mild spoilers ahead.

I greatly enjoyed the “implicit” writing style, atmosphere, and post-apocalyptic setting. Things are casually introduced without too much—or any—explanation, leaving it up to the reader to fill in the blanks.

The whole thing reads like an extended dungeon delve, with main character sometimes being alone, and sometimes allying with one or more individuals. Exploration is very focused on corridors, doors, chambers, and implied threat.

D&D tropes I noticed:

• Character(s) travel down and up the tiered levels of a large subterranean complex.
• It is explicit that deeper levels hold more resources than the upper levels but are also more dangerous.
• Each level has “guardians” of various sorts.
• Exploration is described by providing lengths of corridors, doors, and sizes of areas; almost reading like an example of play, and eerily similar to how I write in the session reports.
• Secret doors and passageways that shortcut the dungeon levels or lead to secret areas with treasure.
• Thematic dungeon levels: a workers' level, laboratory level, pleasure level, engine level, etc.
• Factions: each level has at least one dominant faction, plus several smaller factions.
• Spellcasting. Mostly illusory magic.
• Main character levels up as he travels deeper. He also then has to spend time training to unlock new abilities.
• There is a lot of resting.

Perhaps I read it too quickly, but I do not remember any single character that fits the description of hairy monster featured on the cover.

The novel didn't feel dated at all. In fact, a plague that make peoples' lungs fill with liquid, resulting them in choking to death, sounded very contemporary.

All in all, Sign of the Labrys was quite an enjoyable read. It was fascinating witnessing what might have contributed to Gary's view on dungeons and dungeon delving. I am very much looking forward to reading The Shadow People too.

#Reading #AppendixN #Fantasy #ScienceFiction

I didn’t go to the gym today and so I spent four hours making a massive almost 6 foot tall elephant of cardboard as a decoration for my living room until I get furniture also that I can make this stupid fucking joke of the elephant in the room. To the two friends that I showed it to they lost their shit and thought it was the funny as fuck. And honestly I’m kind of just happy that I get to make things that are silly and stupid and I also cooked today, and it was a very super simple meal but it tasted delicious. It was also very cheap to me and I’m happy that I took the time to do it. A made fun of me and was pretty rude because the dish was not up to her standards, and I did voice how it was out of place for her to say the stuff that she did. She didn’t respond super great but whatever I don’t need her to respond in any kind of way.

I think cooking has started to become a little bit of an insecurity for me, because I’ve had a couple experiences now with female friends that grew up cooking that make fun of me for my inexperience. And it feels really unfair to me because growing up I didn’t even get the chance to cook or to do anything like that, because I was forced to do academics 24/7. A mentioned how she would cook with her family and that was a big bonding time for her and I’m really happy for her and I think it makes it exceptionally shitty to me to have it rubbed into my face how I didn’t have anyone to teach me this stuff. And so I understand that I’m really inexperienced and not super aware of a lot of things that might be common knowledge to someone else. And I understand that it might seem to someone else that I’m completely clueless and naïve, but it’s really hard to try to learn these things on your own without help. It’s one of those things where you don’t even know where to start and you don’t even know what you don’t know. I ruined so many nonstick pans because I was cleaning them wrong and that’s something that might seem super obvious in hindsight but how the fuck am I supposed to know that a pan is not supposed to be scrubbed? And I feel really defensive with stuff like this because I’ve encountered a lot of people that just cannot put themselves in the shoes of remembering what it was like to not know something. And this is something that I’ve noticed a lot as a double standard. For the things that I grew up knowing because that’s all I had as a child, I’ve been very conscious about the fact that not everyone had the same experience as I did and so it’s never someone’s fault for not knowing something when it was something they should’ve been taught. There’s no point in shaming them and it’s not fair to do that either I find. And I think everyone agrees with that philosophy until it comes to something they don’t consider it applicable to.

I mars deltok jeg i en konkurranse hvor målet var å bruke kunstig intelligens for å løse oppgaver, NM i AI. Jeg og en venninne dannet lag og vårt mål var å lære. Resultatet ble deretter, vi havnet omtrent midt på rankingen. Det er ikke noe å skrive hjem om, men nå som det har gått en måneds tid siden jeg var med synes jeg fortsatt jeg lærte noen nyttige ting.

Oppgavene

Konkurransen bestod av tre oppgaver. Den første var levert av NorgesGruppen Data og handlet om å lage en modell som kunne kjenne igjen varer på hyllebilder fra butikker og klassifisere dem. Den andre var levert av Tripletex og handlet om å lage en agent som kunne håndtere oppgaver innen regnskap. Den tredje var an morsom oppgave levert av Astar Consulting (tror de stod for mesteparten av organiseringen). Oppgaven handlet om å lage prediksjoner for hvordan en verden, beskrevet av et pikselert kart med verdier som indikerte bebyggelse eller ikke osv, ville utvikle seg. Her har jeg notert noen av mine tanker rundt oppgaven levert av Tripletex.

Aldri mer skrive reiseregning for hånd?

Tripletexoppgaven var overraskende morsom til regnskap å være. Jeg hater, for eksempel, å levere reiseregninger. Med tilgang til Tripletex' API kan du lage en KI agent som klarer å levere reiseregning for deg bare med en kort beskrivelse av reisen og filer som inneholder kvitteringene. Hvert team fikk utdelt en Tripletex sandbox vi kunne teste agenten vår mot og det gikk overraskende greit å lage en agent som kunne det meste. Det eneste var at jeg måtte bruke den beste modellen fra Anthropic, Opus, for å få det til. Siden jeg var gjerrig (og med vilje ville prøve å få til å lage så billige løsninger som mulig) hadde jeg ikke spandert på meg selv en dyrere tilgang uten ratebegrensninger for Opus. Selv om min agent klarte oppgavene, bare den fikk nok tid, fungerte den dårlig i selve konkurransen fordi vi gikk til timeout før alt var gjennomført.

Billigere (og raskere) modeller

Jeg forsøkte meg på en blanding av modellene Sonnet og Opus hvor Sonnet tok seg av oppgaver i kategorier som var klassifisert som “enkle” og oppgaver av andre typer eller nye oppgaver vi ikke hadde møtt på før gikk til Opus. Dette fungerte ganske godt, men ga også timeout innimellom. Jeg prøvde så å bruke Claude Code til å overvåke loggene fra agenten og komme med forslag til forbedrede instruksjoner og prøve å gjøre instruksjonene så gode at til og med Haiku (raskere modell, men ikke like smart) kunne klare det. Resultatet ble fort at min regnskapsagents instruksjoner ble veldig tilpasset oppgavene i konkurransen og når jeg testet med en større variasjon av instruksjoner mot teamets sandbox feilet agenten brutalt. Haiku begynte å hallusinere endepunkter i APIen og lignende. Vi klarte ikke å lage en agent som både gjorde det bra i konkurransen og fungerte bra hvis vi utsatte den for en større variasjon av forespørsler.

Sikkerhet er krevende

En annen ting var at det var vanskelig å lage en virkelig nyttig agent uten at den også kunne overtales til gjøre sånne ting som å slette alle ansatte. Du vil jo at agenten skal ha tilganger nok til å gjøre alt du trenger at den gjør. Sikkerhet i et slikt system er ikke trivielt. Du kan antageligvis ikke bygge inn sikkerhet utelukkende i instruksjonene du gir din agent, men må ha ett lag i forkant av selve agenten som filtrerer vekk det som virker som skadelige prompts OG et lag mellom agenten og faktisk gjennomføring av forespørsler mot API som utelukker skadelige handlinger. Som å slette alt av bilag eller alle ansatte.

Leverandøravhengighet

I et produksjonsmiljø vil det nok være nærliggende å velge å bruke Opus, den dyreste og beste modellen fra Anthropic, eller tilsvarende fra en annen leverandør. I dag er nok tilgang til slike modeller underpriset sammenligned med hva det faktisk koster å vedlikeholde og videreutvikle slike ledende modeller. Likevel brukte laget vårt i overkant av 200 kroner på tokens en helg og da brukte vi mye Haiku og Sonnet, som er rimeligere. I dag bygger nok mange bedrifter tjenester basert å de beste modellene. Hva gjør man med tjenesten hvis leverandørene bestemmer seg for å sette opp prisen? Det var alt annet enn lett å bytte ut Opus med billigere alternativer. Jeg gjetter på at de største leverandørene fortsatt selger tilgang til en slags introduksjonspris og at den dagen mange nok har bygget opp avhengigheter, så vil prisen øke.

Du må nok skrive reiseregningen selv

Hvis vi, som hadde tilgang til en del gratis tokens (jeg hadde nettopp satt opp abonnement på Claude og hadde derfor noen gratis introduksjonstokens), brukte over 200 kroner på noen timer med forespørsler, hvor mye vil ikke det tilsvarende koste hvis en hel bedrift bruker det? Det skal godt gjøres å forsvare, økonomisk, å ha en agent som kanskje, kanskje ikke gjør som du vil heller enn å bare forvente at folk leverer sine egne reiseregninger. Hadde jeg vært sjef, så hadde jeg nok sagt at folk pent må laste ned den appen og taste inn de detaljene selv.

En smartere bruk

En smartere bruk kunne vært å utvikle en agent som hjelper regnskapsarbeidere utvikle, sammen med IT-folk, løsninger som automatiserer de mest tidkrevende oppgavene. Da utnytter du modeller som Opus' kapasitet til å finne fram til riktige API endepunkter og lignende på en måte som gjør det enklere å bygge inn sikkerhet og tilgangsstyring.

Many things have happened since the previous new moon, planet-dwellers.

Someone in my chosen family told me: “Simplify your life. And then simplify again. Happiness follows.”

When I think about it, some things are best left unsaid and un-announced to the wider public. Everyone will be happier that way.

What news can I then bring you on this new lunar cycle, my fellow esteemed gaia-naut?

I know! Let me check the logs on my camera, (a beauty from the digital-camera manufacturers of the 2010s.)

snapshots

Note: the above has been edited with an app named Snapseed.

from another camera

tried a journal prompt: what I have learnt that I need in love

It's so strange that people around me, myself included, need a new useful language to advocate for what we really need. The language from my childhood environment is insufficient for my present-day circumstances.

To help me, I used a checklist from Dr. William Harley, Jr.'s book, titled “His Needs, Her Needs”. A striking sentence from that book is: affairs begin when someone in the marriage feels unfulfilled in their emotional needs, and looks elsewhere to fulfill those needs: co-workers, strangers and so on.

Dr. Harley, Jr. lists out ten different emotional needs in his book.

After working through some exercises, I have compiled a ranking of my top five emotional needs, out of the ten. In this particular order:

1. Gestures of affection
2. Recreational companionship
3. Words of admiration
4. Physical attractiveness of my partner (lest anonymous critics accuse me of sexism, I believe my partner would similarly love for me to look well-groomed and well-dressed.)
5. Intimate conversations – about fears, vulnerabilities and future hopes.

I wonder, dear reader, if you and your partner discuss whether each of you are meeting each other's needs? For me, I realised it takes substantial effort to even figure out my emotional needs in the first place – with the caveat, of course, that my emotional needs may change as time passes.

bookshelf

1. Sun City, by Tove Jansson.
2. The insanity of God: A true story of faith resurrected, by Nik Ripken.
3. Illustration now: Fashion, edited by Wiedemann and Heller.

resources

1. “Affection, sex and the 10 emotional needs”. By: Mark Jala. Retrieved from Happy Marriage Coaching on 16 April 2026. Also on Internet Archive.
2. Journal prompt cards, from Oliver Bonas, (which is the name of a chain of stores.)

#lunaticus

Jesus began the day in quiet prayer at Steele Indian School Park while the sky was still more night than morning and the city had not yet fully remembered itself. The grass held the last of the dark. The water lay still and flat under the weak early light. The old buildings stood with that strange kind of silence that feels heavier than empty, as if memory itself had settled there and never fully moved on. He knelt near the edge of the path where the breeze moved through the trees in a soft and steady way. There was no audience. There was no performance in Him. He bowed His head and prayed with the kind of calm that made everything around Him feel less scattered. A woman in a faded blue sedan sat thirty yards away with the engine off and both hands locked around the steering wheel like she was trying to keep herself from coming apart. She had pulled into the park because she could not bear to go home yet, and because crying in a place with trees felt less humiliating than crying in a grocery store parking lot or at a red light where somebody could glance over and watch her break. Her name was Elena Ruiz, and she had spent so many years being the one who held everything together that she no longer knew what to do now that everything was slipping through her fingers anyway.

She had not planned to stop at the park. She had planned to drive straight back to the apartment near Thomas Road, change clothes, wake her father for his morning pills, and pretend for another day that they were still only a few hard weeks away from being okay. But when she found the pink notice tucked under her wiper in the lot behind the office building where she cleaned hallways at night, something in her finally gave way. It was not even the worst thing she had seen that week. The rent reminder folded on her kitchen counter was worse. The text from her daughter the night before had been worse. The call from her younger brother asking if she could spot him eighty dollars had been worse only because he had asked it with the same careless voice he always used, as if her life were still a place where money appeared when she needed it. Yet that pink notice had done something the other problems had not. It had taken all the things she had been trying to carry separately and stacked them into one undeniable truth. She was behind. She was tired. She was losing ground faster than she could make it back. Her father had started forgetting small things and then pretending he had not. Her daughter Sofía had grown quieter and sharper at the same time. Elena’s body ached in ways that sleep no longer fixed. She had driven until the streets widened and the city thinned around her and then she saw the park and pulled in because she did not trust herself to keep moving.

She watched Jesus before she knew why she was watching Him. At first He was only a figure at the edge of the path, kneeling alone in the weak dawn. There was nothing flashy about Him. He did not look like the kind of man people in her neighborhood would automatically move toward. He looked simple. Steady. Completely at ease in a world that made almost everyone else look rushed or guarded or tired. Elena brushed tears from under her eyes with the heel of her hand and told herself to get a grip. She was too old to be falling apart in parking lots before sunrise. She was too needed for this. She had a father at home whose pill organizer sat on the counter waiting for her. She had laundry in the back seat. She had a sink full of dishes. She had a daughter who had become impossible to read. When Jesus rose from prayer, He did not look around as if checking to see who had noticed. He simply stood and turned toward the path. An older man across the grass had dropped a plastic bag and two oranges rolled out toward the curb. Jesus crossed to him without hurry, bent down, picked them up, and listened while the man spoke. That should not have mattered. It was a small thing. Yet Elena felt the sting of tears again because lately nobody in her life seemed to have time for small things unless they were attached to a bill or a problem or a demand. She started the car, then turned it off again. Then she started it once more and finally backed out with a hard swallow, telling herself that whatever was rising in her was only exhaustion.

By the time she reached the apartment, the sun had started to color the edges of the buildings and the day had taken on the dry brightness that always made Phoenix feel more awake than she did. Her father, Luis, was already dressed when she walked in, though one sleeve of his button-up shirt was misbuttoned and his shoes were on the wrong feet. He sat at the small kitchen table with yesterday’s mail spread in front of him as if he had been studying it, but the look on his face told her he had mostly been staring through it. He had once been a man who could fix engines by sound and could tell you what was wrong with a room within ten seconds of stepping into it. Now he sometimes forgot the word for dishwasher. Sometimes he opened the freezer when he meant to use the bathroom. Most days he recovered quickly enough to make a joke. Some days he got angry first. Elena moved toward him without mentioning the shoes because there was a right way to help him and a wrong way, and the wrong way could turn the whole morning into a wound neither of them knew how to close. Sofía was asleep on the couch with one arm across her face, still in black work clothes from the night before. Her eyeliner had smudged beneath her eyes. Her shoes were on the floor, one near the coffee table and one halfway under the lamp. Elena looked at her daughter for a moment and felt that old mixture of tenderness and helpless frustration. Sofía was nineteen. She was smart. She had once laughed easily. Lately she moved through the apartment like every question from her mother was an accusation.

Luis looked up when Elena reached for the coffee pot. “You’re late,” he said, though he said it without force, as if the sentence had arrived before the feeling behind it. Elena glanced at the microwave clock and almost corrected him, then stopped herself. “Traffic,” she said instead. “Did you eat?” He nodded once. Then he frowned at the table and lifted one of the envelopes. “This from the power company?” he asked. The fact that he had to ask made something inside her tighten. He had always been the one who sorted papers, paid bills, balanced the world with a pencil and a pad and a kind of plain competence that made fear feel unnecessary. Elena took the envelope from him and set it aside. “I’ll handle it,” she said. He did not like those words anymore. She could see it in the way his mouth moved. He did not want his daughter handling things for him. He did not want her speaking gently to him as if he might bruise. He did not want the world narrowing one forgotten word at a time. From the couch, Sofía spoke without opening her eyes. “Everything in this house is ‘I’ll handle it,’” she muttered. “That’s not actually handling it.” Elena turned too fast. The exhaustion in her body made her temper feel closer to the surface than usual. “You got in after two,” she said. “I’m not doing this right now.” Sofía sat up, pushed her hair back, and looked at her with that blank hard stare that had become her shield. “No, of course not,” she said. “We never do.”

Elena had planned to sleep for an hour after breakfast, but by eight-thirty she was back in the car with Luis beside her because the apartment felt too tight and because the forms she needed for rental assistance were easier to print at Burton Barr Central Library than from her phone. She told Sofía where she was going. Sofía nodded without really listening and said she had to be downtown later. Elena wanted to ask where exactly. She wanted to ask whether classes mattered to her anymore. She wanted to ask who she had been with the night before. Instead she said, “Don’t forget to eat something,” and hated the way the sentence sounded thin and powerless the moment it left her mouth. The drive south was mostly quiet. Luis kept touching his shirt pocket, then the dashboard, then his pocket again. Elena noticed it by the second stoplight. “What are you looking for?” she asked. He hesitated, which told her he had known the answer a minute ago and now did not. “Nothing,” he said. Then after a pause, “My wallet.” Elena exhaled slowly. “It’s in your back pocket,” she said, keeping her voice light. He reached back, found it, and looked out the window without another word. Shame had a way of entering a car and taking up all the room. It sat between people without sound. It made every kindness feel dangerous.

The library had the kind of clean quiet that could either settle a person or expose them. Elena never knew which way it would go. Burton Barr always felt larger on the inside than the building looked from the street. The light came down in long bright stretches, and the people moving through it seemed to carry whole private worlds no one else could see. A man in construction boots slept in a chair near the entrance with his lunch cooler between his feet. A woman with a toddler balanced a stack of children’s books against her hip while fishing in her purse for a library card. Two teenagers argued softly over a phone charger. Elena guided Luis toward a bank of computers and signed them in, then sat at the screen with the folder from home tucked under her arm. She had brought every paper she thought she might need. Pay stubs. Her lease. The utility notice. Her ID. Luis’s medication summary from the clinic. The neatness of it almost mocked her. She had the paperwork of a responsible person and the life of someone one bad month away from collapse. Luis wandered toward a display of local history books while she opened forms and filled blank spaces with fingers that felt clumsy and too large. Household income. Number of dependents. Current balance due. Reason for hardship. That one stopped her. She stared at the blinking cursor. There were too many reasons, and somehow writing any of them down made them feel both smaller and more humiliating.

When she finally rose to find the printer, she saw Jesus standing near the far end of the room beside her father. Luis had one hand resting on the back of a chair, and there was a look on his face Elena had not seen in weeks. It was not happiness. It was not exactly relief. It was the look of a man who had been bracing for laughter and had instead found gentleness. She moved toward them quickly, unsure whether to apologize or protect or explain. Jesus turned before she spoke, as if He had known she was there the whole time. Up close, His calm did not feel distant. It felt attentive. Fully here. Fully with the person in front of Him. Luis tapped the front pocket of his shirt and said, “I thought I’d lost the card with my prescription list.” He held up a folded paper. “I had it the whole time.” Elena looked from the paper to her father’s face. The edge in him had gone soft. Jesus said, “Sometimes fear makes us think something is gone before it is.” It was a simple sentence. Elena should have let it pass as one more kind stranger offering one more harmless observation. Instead she felt the words settle somewhere deeper than they should have. Because that was exactly how the last few months had felt. As if she had started declaring parts of her life dead before she had even stopped to see what was still there. As if panic had become the lens through which she viewed every unopened envelope, every short reply from her daughter, every quiet lapse in her father’s memory.

Luis, who usually distrusted men he had not measured for himself, asked Jesus if He came to the library often. Jesus smiled in a way that made the question feel welcome rather than small. “I go where people are trying to carry more than they can name,” He said. Luis gave a short breath that almost became a laugh. “Then you picked the right building.” Elena should have interrupted. She should have thanked Him and moved on. She still had forms to print. She still had an afternoon to survive. Yet she stood there feeling oddly seen and unprotected at the same time. Jesus looked at her then, not at her folder or the lines of fatigue beneath her eyes, but at her. “You have not rested in a long time,” He said. She almost told Him that was none of His business. The answer rose hot and ready in her throat. But something about His tone made defensiveness feel childish. He was not intruding. He was naming what was already true. Elena lifted one shoulder. “People don’t always get to rest,” she said. “Some people have to keep things moving.” It was the kind of answer she gave everyone. It had become her way of ending conversations before anybody could step into the places she kept hidden. Jesus did not argue with her. He simply said, “Keeping things moving is not the same as being held.”

That sentence followed her back to the computer and would not leave her alone. Keeping things moving is not the same as being held. Elena printed the forms, then reread them twice because suddenly the whole process made her feel exposed. She hated asking for help from systems built by strangers. She hated the language of need. She hated the way forms reduced a life to numbers and categories and boxes that did not care how hard she had worked to avoid this very moment. A library staff member wearing a purple lanyard stepped over and asked if she needed community resources. Elena nearly said no out of reflex, but the woman’s face was kind and practical and carried none of the pity Elena feared most. She mentioned food assistance, rental programs, and a legal clinic that came twice a month. Then she said, “If you need groceries before anything else comes through, St. Mary’s can help today.” Elena nodded as if she were only taking in information for someone else. She folded the handout and slid it into her folder without looking at it. Food assistance was for people in emergency. For people at the bottom. For people who had run out. Yet even while the thoughts moved through her, she knew they were lies she had inherited from pride and fear. Her refrigerator was not empty, but it was thinning in that unmistakable way. Eggs. A half onion. Tortillas. One yogurt. A jar of salsa. Rice. Her father needed better than that. So did Sofía, whether she acted like the apartment no longer mattered to her or not.

Luis asked if they could sit for a few minutes before leaving. Elena agreed, mostly because the room had begun to feel too bright. They found seats near a window where the city shimmered beyond the glass in sheets of white heat. For a while neither of them spoke. Then Luis said, “I forgot your mother’s birthday last month.” Elena turned toward him slowly. He had not told her that before. Her mother had been gone three years, and the grief had shifted shape but never really loosened its grip. “It came to me later that night,” he said. “I sat there thinking I had missed something. Then I knew what it was and I could not fix it.” Elena swallowed hard. Her father kept his eyes on his hands. “When your mother was alive,” he said, “I was the one who remembered. All the dates. All the appointments. I knew when the tires needed air. I knew who needed a ride. I knew how to keep things straight. Now I stand in the kitchen and look at a spoon and for a second I don’t know why I’m holding it.” Elena reached for his hand, and he let her, which was its own kind of heartbreak. “You’re still here,” she said. He nodded but did not look convinced. “That’s what people say when they want to be kind,” he answered. “It isn’t the same as being who you were.” Jesus, who had somehow crossed the room without Elena noticing, stopped near them with the quiet ease of someone entering holy ground. He looked at Luis and said, “You are not less loved because you are frightened by what is changing.” Then He looked at Elena and added, “And you are not stronger because you refuse to admit you are frightened too.”

Elena almost laughed, but it would not have been a real laugh. It would have been the laugh a person gives when they are too close to crying in public and need some other sound to come out instead. She stood too quickly and said they should go. On the way out, the folded handout inside her folder seemed heavier than the papers themselves. Outside, the light had sharpened and the sidewalk held that dry midday glare Phoenix wore like a challenge. Luis asked whether they were heading home. Elena heard herself say no before she had fully decided. “We’re making one more stop,” she told him. He did not ask where, though she suspected he knew from the tightness in her voice that whatever answer she would have given would have embarrassed her. She drove west with the air conditioner pushing against the heat and with the silence in the car deepening into something more honest than the earlier shame. There were moments in life when you could feel yourself crossing a line you never meant to approach. Not because disaster had exploded, but because a quiet truth had finally become too large to step around. Elena had always believed she could work her way clear of trouble if she moved fast enough and gave up enough sleep. That belief had carried her a long time. It had also become its own prison. At a stoplight she pressed her thumb into the center of the steering wheel and fought the urge to turn around. “We don’t have to,” Luis said softly, still looking out the window. Elena did not ask how he knew. “Yes,” she said after a moment. “We do.”

St. Mary’s Food Bank did not look the way shame had described it in her head. It was orderly. Busy. Human. People stood in line with strollers, with folding carts, with toddlers clinging to knees, with work boots dusty from a job site, with office clothes still neat enough to suggest they had come on a break and hoped nobody they knew would see them. That hurt Elena more than it helped because it forced her to admit how wrongly she had imagined need. Need did not announce itself with one face. It did not live only in lives that had gone completely off the rails. It moved quietly into ordinary houses and sat down at ordinary tables and began taking things one paycheck at a time. She parked and sat without unbuckling. Luis waited beside her. He did not rush her. He was proud enough to understand what pride cost. Finally Elena got out, smoothed the front of her shirt, and took the folder with her as if documentation could somehow defend her dignity. The line moved slowly under the hard white afternoon. Somewhere near the front a baby cried with the exhausted full-body cry that comes just before sleep. A volunteer handed bottled water to people waiting. Elena took one and thanked the woman in a voice that sounded unfamiliar to her own ears.

About ten minutes later she heard somebody say her name with the hesitant tone of a person who is not sure they want to be recognized. She turned and saw her brother Nico three places over, wearing an orange volunteer shirt and carrying flattened cardboard boxes toward a side bin. He had lost weight since she had last seen him, though in his case that only made the strain in his face easier to read. Nico was thirty-seven and had spent most of his adult life living as if consequences were weather systems that formed only over other people’s houses. He had charm when he wanted something. He had apologies when charm failed. He had plans every January and excuses every March. Elena loved him in the stubborn way family often forces love to work, but she had run out of belief in his promises a long time ago. Seeing him there hit her in two directions at once. Part of her wanted to turn away because standing in that line already felt like enough exposure for one day. Another part of her could not ignore the simple fact that he looked ashamed to be seen. He set the cardboard down and came toward her with the awkwardness of someone approaching a bruise. “Court stuff,” he said before she could ask. “Community service. It’s not permanent.” Elena almost told him she had not asked for an explanation. Then she looked at his face and saw that he was not trying to get ahead of judgment this time. He was trying to survive it. “How long?” she asked. “Three weekends,” he said. “And maybe longer if I keep coming.” Luis gave him a nod. Nico returned it with surprising gentleness.

They did not have time for a full conversation because the line kept moving, but a few hard things can surface quickly when people are no longer strong enough to keep acting. Nico glanced at the folder under Elena’s arm, then at the line, and something in him shifted. “You okay?” he asked, and for once there was no foolishness under the question. Elena looked away. “I’m managing.” Nico winced a little at that word, which told her he knew exactly how false it had become. “Sofía’s been picking up shifts at The Duce,” he said after a pause. “You know that, right?” Elena stared at him. “She told me she was covering here and there.” Nico rubbed his jaw. “It’s more than here and there.” He lowered his voice. “I saw her outside a couple nights ago. She looked wrecked. Said not to tell you.” Elena felt the heat change around her. Not because the sun had shifted, but because something inside her had. “Why would she tell you and not me?” Nico gave a tired half smile. “Because I’m the family disappointment. People say things around me they won’t say around the person still trying to keep the walls up.” That should have irritated her. Instead it landed with painful accuracy. She thought of Sofía on the couch that morning, shoes on the floor, face turned away. She thought of all the questions she had asked lately that were really accusations with softer wording. She thought of how often fear made love sound like control.

Jesus was there again before Elena had decided what to do with this new ache. She had not seen Him arrive. He was simply beside them, one hand resting lightly on the handle of an empty cart, as if He had always been part of the line. Nico looked at Him with quick curiosity, then with the wary respect people sometimes feel around someone who seems to know them before introductions. Jesus said to Elena, “Not every silence in your daughter is rebellion. Some of it is pain she does not know how to bring to you without feeling judged or becoming a burden.” Elena opened her mouth to defend herself and found that nothing honest came easily. She loved her daughter. She had worked through fevers for her daughter. She had gone without new shoes for years for her daughter. Yet love by itself did not mean Sofía felt safe with her. That realization hurt in a place deeper than pride. Nico looked down at the concrete. “That’s true,” he said quietly. “She’s been scared for a while.” Elena turned to him too quickly. “Scared of what?” Nico hesitated, and in that hesitation she heard enough to know there was more waiting for her than she was ready to hear. The line moved again. A volunteer waved them forward. Luis touched Elena’s elbow, not to hurry her but to steady her. She walked on because there was nothing else to do. Sometimes grace does not arrive by removing humiliation. Sometimes it arrives by keeping a person standing while they walk through it.

When they came back to the car with boxes in the trunk and a few extra bags tucked at Luis’s feet, the day had tilted toward afternoon. Elena leaned against the door with both eyes closed. She was grateful. She hated that she was grateful. She felt lighter and rawer at the same time. Nico stood a few feet away, hands in the pockets of his volunteer pants, as if unsure whether he had earned the right to stay near them. “I can meet you downtown after I’m done here,” he said. “At The Duce. If you want.” Elena opened her eyes. “Why would I need to meet you there?” Nico looked at the pavement before answering. “Because Sofía’s not just working extra. Something happened with school. And I think she’s trying to outrun it.” Elena’s stomach tightened. She thought of tuition notices. Missed assignments. Quiet panic. The way Sofía had begun sleeping with her phone under the pillow. The way she snapped whenever Elena asked about classes. Jesus stood near the front of the car with the late light on His face, and in that moment He did not look severe or distant or dramatic. He looked like the only steady thing in a city full of people trying not to drown where others could see. “Go to her,” He said. “But do not go armed for a fight. Go ready to hear what her fear has been saying when her mouth could not.” Elena drew in a shaky breath. She wanted to ask how she was supposed to do that when her own fear was screaming just as loudly. She wanted instructions. A script. A guarantee that one right conversation could restore what months of strain had thinned. Instead all she had was the look in His eyes, which carried neither pressure nor doubt. Luis eased himself into the passenger seat. Nico stepped back. Elena got behind the wheel and gripped it the way she had at dawn, except now she knew that whatever was waiting in downtown Phoenix would not be answered by pretending she was still the unbreakable one. She started the engine, pulled out into the traffic, and drove toward The Duce with Jesus moving beside the wreckage of her day as calmly as if none of it was beyond redemption.

Traffic thickened as she moved south and east through downtown, and the city took on that late-afternoon look that always made Phoenix feel both exposed and full of hiding places at the same time. Heat rose from the streets in waves. Light flashed off windows. Men in work shirts crossed against the signal with paper cups in their hands. A woman pushed a stroller past a bus stop while talking into a phone with the tired sharpness of someone handling too much before dinner. Elena drove with one hand tight on the wheel and one hand resting uselessly on the folder in the passenger seat as if papers could do something here too. Luis stayed quiet beside her, though once he reached over and touched the edge of the food bank receipt sitting near the cup holder. He did not say that he hated being a man who rode home with donated groceries at his feet. He did not have to. The whole day had been full of things nobody wanted to name because naming them made them feel too solid. Nico followed in his own car after his shift ended, and the knowledge that her brother was behind her somewhere in traffic felt strange. He had been one of the least dependable people in her life for so long that having him near her on a hard day felt like watching a familiar street show a different face in different light.

By the time she parked near The Duce, the place was alive with its usual mix of noise and motion. People drifted in and out of the old warehouse space with drinks, laughter, tired postures, and the kind of faces that said they had come looking for one night off from themselves. Elena had only been there once years ago for somebody’s birthday, and even then she had never felt fully at ease in places where everybody seemed determined to prove they were having a good time. Now the whole setting pressed against her nerves. Music leaked through the open space. A few people stood near the entrance looking relaxed in ways she could not imagine feeling. Nico met her by the car and glanced toward the building. “She’s probably in back or near the side entrance,” he said. “Sometimes she takes her break out there.” Elena looked at him hard. “What happened with school?” Nico rubbed the back of his neck and looked older than she usually let herself notice. “She withdrew,” he said. “I don’t know every detail. I just know she was trying to keep it from you. She said she was gonna get through the semester somehow, but I think it got away from her.” Elena felt the ground inside her shift. She had suspected struggle. She had not let herself imagine collapse. “How long have you known?” she asked. Nico gave a tired shrug that carried shame in it. “A few weeks. She made me swear not to say anything.” Elena turned away before she said something cruel. Anger comes easily when pain arrives wearing the face of secrecy. It wants a target before it wants truth.

Jesus stood near the side wall under a sliver of shade as if He had always belonged there too. The noise of the place did not touch Him. The pressure of the day did not rush Him. He watched Elena the way a doctor might watch a patient reaching for a wound that has finally opened. “If you walk in there trying to recover your pride,” He said, “you will lose your daughter for the rest of the evening. If you walk in ready to understand her fear, you may finally hear her.” Elena shut her eyes for one second because she knew He was right and hated it. She had not spent the drive preparing to understand. She had spent it collecting hurts. She had spent it building the case she might make against Sofía without even meaning to. The hidden shifts. The withdrawal from school. The distance. The way her daughter had forced Elena to hear hard things from everybody else first. Luis got slowly out of the car and closed the passenger door with both hands. He looked at Jesus and then at Elena. “Your mother used to say that when people are ashamed they lie badly and hide poorly,” he said. “It doesn’t always mean they don’t love you.” Elena swallowed hard. Her father had not quoted her mother in weeks. The fact that he remembered that now felt like mercy breaking through a wall in a place she had stopped expecting it.

They found Sofía near the back by a service door with an apron tied loosely over black jeans and a phone in her hand. She was sitting on an overturned crate with one knee up and one foot tapping the concrete, staring at something on the screen so intensely that she did not see them at first. When she did, her whole body changed. Elena saw it happen before any words were spoken. Her daughter’s shoulders locked. Her mouth set hard. Her eyes narrowed not with anger first, but with the panic of a person whose private damage has just been discovered in public. “What are you doing here?” Sofía asked, getting to her feet too fast. Elena almost answered with the full weight of what she felt. She almost said, That depends on why you’ve been lying to me. She almost said, I had to find out from your uncle. She almost said, After everything I’m carrying, this is what you do. But Jesus’ words were still in her. Go ready to hear what her fear has been saying. Elena took a breath that felt thin and said, “I came because I need to talk to you.” Sofía laughed once, but there was no humor in it. “Now?” she said. “At work? That’s great.” Nico stayed back. Luis rested one hand against the car beside him. Jesus stood a few steps away, not forcing Himself into the center and yet somehow remaining there.

Sofía crossed her arms and waited, but Elena could see that she was already bracing for attack. That hurt more than the lies had. A child only learns to brace like that when home has stopped feeling like a place where hard truth can arrive without explosion. Elena felt the sharp sting of that realization and had to steady herself against it before speaking. “I know about school,” she said. The words were simple, but the effect was immediate. Sofía looked past her mother toward Nico, then back again, and the betrayal in her face turned quickly into fury because fury is easier to carry than humiliation. “Of course you do,” she said. “Why would anybody tell me my own life belongs to me?” Elena should have flinched. Instead she heard the wound under the sentence. “I’m not here to trap you,” she said. “I’m here because I should have known you were drowning.” Sofía’s face changed again. The hardness did not vanish, but it lost some of its edge. “You were busy,” she said, and that sentence entered Elena more painfully than shouting would have. Busy. It was true. She had been busy keeping food in the house, sorting Luis’s appointments, working nights, staring down bills, answering texts, doing laundry, fixing small things before they became large things. She had also been busy telling herself that surviving the week was the same as staying close to the people she loved.

Sofía looked away toward the alley, where heat still pressed off the pavement and the noise from inside the building rose and fell behind them. “I didn’t withdraw because I’m lazy,” she said in a lower voice. “I know you probably think that.” Elena started to interrupt, but Jesus’ presence held her still. Sofía kept going before she lost the nerve. “I missed one class because Grandpa had that bad morning and you were asleep after work. Then I got behind. Then I tried to catch up. Then I started having panic attacks every time I opened the course site. Then one of my professors emailed asking if everything was okay, and I couldn’t even answer because I felt stupid. Then I bombed a presentation because I couldn’t breathe and everybody stared at me like I was losing my mind. Then it was too late.” Her voice cracked on the last three words, and she hated that it did. Elena could see it. Sofía pressed her lips together and looked down at her hands. “I thought maybe I could keep the job and save some money and go back later and tell you once I had a plan.” Elena heard every missed chance in the space between them. Every moment she had asked, “How’s school?” while looking at the sink or folding towels or scanning unpaid bills instead of looking into her daughter’s face. Every time Sofía had said, “Fine,” and Elena had accepted it because the truth sounded too large to handle that day.

“You should have told me,” Elena said, but gently this time, and even she could hear that the sentence carried sorrow more than blame. Sofía gave a small bitter shake of the head. “And said what?” she asked. “Hey Mom, I know you’re holding up the whole house and taking Grandpa to appointments and trying not to get evicted, but good news, I’m falling apart too?” Elena opened her mouth and then closed it because this was the real confession, not the withdrawal form. Sofía had not hidden things because she did not care. She had hidden them because she could see her mother’s exhaustion and had mistaken that exhaustion for inability to hold anything else. She had decided silence was kindness. A terrible kindness. A lonely kindness. One that left her stranded inside her own fear. Jesus stepped nearer then and spoke so calmly that the noise behind them seemed to thin around His words. “Children often begin carrying secret weight when they stop believing there is room for their pain in the house,” He said. Sofía’s eyes filled, and Elena felt her own. “I never wanted that,” Elena whispered. “I know,” Jesus said. “But love can still grow sharp when it is frightened long enough.”

For a while nobody moved. Cars rolled past on the street beyond the lot. Somebody inside laughed too loudly. A kitchen door swung open and shut. The ordinary world kept going while a family stood in an alley and faced what had been fraying in silence for months. Nico looked wrecked by it too. He leaned against the wall with both hands in his pockets and stared at the ground like a man who had no business offering wisdom and yet was about to try anyway. “We all do this,” he said quietly. “We all act like the family only gets one person who’s allowed to need help at a time.” Elena turned toward him. It was such a true thing that she felt it more than thought it. Luis nodded once, slowly, with a sadness that seemed to reach back through years. “Your mother carried things she never told me either,” he said. “By the time I understood, she had been alone in them longer than I knew.” He looked at Sofía then with watery eyes and an expression so tender it nearly undid Elena. “Don’t make the house quieter than it already is,” he said. “Silence can eat a family.” Sofía covered her mouth with one hand and looked away because some truths are too sharp to take head-on.

A young woman with a stack of towels under her arm opened the back door, saw the faces in the alley, and immediately slowed. She was around Sofía’s age, maybe a little older, with a tattoo disappearing under one sleeve and the careful expression of somebody who had seen enough pain in public to know when to step lightly. “You okay?” she asked Sofía. The question was simple, but it held no performance. Sofía gave the automatic answer first. “Yeah.” Then she looked at the woman again and shook her head. “No. Not really.” The woman shifted the towels against her hip. “You want me to cover ten more minutes?” she asked. Sofía nodded. The woman said, “Done,” and slipped back inside. It was such a small act. Yet Elena felt it deeply because all day Jesus had been showing her this same truth in different forms. Help does not always arrive grandly. Sometimes it enters by way of an older man with dropped oranges, a library worker with a resource sheet, a volunteer handing out water, a brother telling the truth at last, a coworker covering ten more minutes. Pride always imagines rescue has to look dramatic before it counts. Grace almost never agrees.

Elena sat down on the low curb by the wall because her legs had started to feel unreliable. Sofía remained standing for a second, then finally sat too, leaving a careful little distance between them. It was not rejection. It was uncertainty. It was the distance of two people who loved each other and had both grown used to speaking around the real thing. Elena looked at her daughter’s profile and suddenly saw not just the young woman in work clothes, but the child who used to fall asleep in the back seat after church, the teenager who once cried in the bathroom before a school performance and let Elena hold her face in both hands, the girl who had once believed her mother could answer anything. “I’m sorry,” Elena said. She did not rush the words. She did not bury them under explanation. “I’m sorry I got so locked into surviving that you started thinking your pain had to wait its turn.” Sofía stared straight ahead for a long moment. Then she said, “I’m sorry I lied.” Another pause. “And I’m sorry I started looking at you like you were the enemy every time you asked me a question.” Elena gave a sad little breath. “Half the time I was asking like a cop, not a mother.” That pulled the smallest almost-smile from Sofía, and because it came through tears, it felt more valuable than a full easy laugh would have.

Jesus lowered Himself to sit on the curb a few feet away as if He had all the time in the world and as if no one there needed to earn the right to have Him stay. “Truth can reopen a home,” He said. “But only if the truth is met with mercy.” Elena looked at Him. “I don’t know how to fix all of this,” she admitted. “I can’t fix rent and school and my father’s mind and whatever else is still coming.” Jesus nodded once. “No,” He said. “You cannot fix a whole life in one afternoon. But you can stop making people hide from you while they are hurting. That is where healing begins.” Sofía wiped under one eye with the back of her wrist. “What if I already messed too much up?” she asked. Jesus turned to her. “Then you begin from the truth instead of from performance,” He said. “Many people lose years trying to look unbroken.” Nico laughed softly at that, but there was pain in it. “That sounds familiar,” he said. Jesus looked toward him too. “It should.” Nico dropped his eyes. For perhaps the first time Elena saw her brother not as the family problem, but as another frightened person who had spent years trying to outrun his own shame through charm, noise, and motion. The thought did not erase damage. It did soften the old hard categories in her mind.

They stayed there longer than Elena expected. The sun lowered enough to take some of the cruelty out of the light. Sofía told them about the first panic attack, the one that happened in a campus bathroom when she realized she could not finish an assignment because she had not really slept in two days. She told them about sitting on the floor with her back against the stall door and hating herself for being dramatic while her heart pounded so hard she thought she might pass out. She told them about deleting draft emails to professors because every version made her sound weak. Elena listened without interrupting. It was harder than she expected because mothers often mistake restraint for passivity, but she was beginning to understand that listening without rushing to correct or solve can be its own form of love. Luis said little, though once he reached out and touched Sofía’s shoulder with trembling fingers and said, “I’m sorry for the mornings you had to see me confused.” Sofía took his hand and held it against her arm. “I never minded helping Grandpa,” she said. “I just got scared that if I admitted I couldn’t do everything else too, I would be one more problem.” Elena closed her eyes for a moment because there it was again. The same lie wearing a different face. Every person in the family had begun protecting the others through silence, and the silence had nearly eaten them alive.

When Sofía had to go back inside, Elena asked if she could finish the shift and then meet them somewhere quieter. Sofía hesitated, then nodded. “Encanto Park?” she said. “I used to like it there.” Elena smiled sadly. “Me too.” Nico offered to pick up cheap takeout on the way, and for once Elena did not tell him no before he had the chance to prove he might actually follow through. She and Luis drove slowly west while the city softened into evening. Jesus was with them again, though not in the way panic imagines rescue must happen. He did not take the wheel. He did not make every bill disappear. He did not announce that tomorrow would be easy. He simply remained. It is a great mercy when the presence of someone good steadies the air in a car where people have spent too many months breathing fear. Luis dozed for ten minutes with his head near the window. Elena drove past familiar streets with unfamiliar quiet in her chest. Not peace exactly. Peace was too strong a word for a day like this. But something had changed. The lies were no longer locked inside separate rooms. The truth was out now. Pain had names. Shame had been interrupted. That matters more than people realize. Many homes do not first heal when circumstances improve. They first heal when pretending loses its place of honor.

Encanto Park held the evening in a gentler way than the rest of the city. The water caught the last light in broken lines. Children called to each other near the path. An older couple walked slowly under the trees with their hands linked and their steps practiced to the same rhythm. Elena sat on a bench while Luis stared across the pond as if trying to remember some older version of his life that had once moved at a steadier pace. Nico came fifteen minutes later with paper bags that smelled of grilled meat and onions and warm tortillas. He looked faintly surprised at himself for having shown up on time. “I figured nobody needed another disappointment tonight,” he said, setting the food down. Elena looked at him for a long second and saw that he meant it. “Thank you,” she said. He nodded and sat on the far end of the bench like a man who still was not sure whether he belonged there. Sofía arrived after sunset had begun to deepen, carrying no apron now and no phone in her hand. She looked younger without the work face she had worn at the alley. She sat beside Elena, and this time she did not leave space between them.

They ate slowly and talked in the kind of uneven honest way families do when the ice first begins to break. Not beautifully. Not with sudden perfect insight. Nico admitted he was behind on his own rent too and had been too embarrassed to say it. Elena almost laughed at the absurdity of how much hidden fear had been living under one family name. Sofía said she wanted to talk to the college about coming back later instead of pretending the whole dream was dead. Luis, after losing the thread twice and finding it again, said he wanted Elena to stop treating rest like sin. “Your face always looks like you’re bracing,” he told her. “Even when you’re sitting down.” She smiled through tears because she knew he was right. Jesus listened more than He spoke now. It was as if once truth had entered the night, He was content to let it do some of its own work. At one point a little boy near the water tripped and began wailing, and before the boy’s father could reach him, Jesus was already there, crouching, brushing dirt from small scraped hands, calming him with a voice so gentle that the crying eased almost at once. The father thanked Him with the distracted gratitude of a tired parent. Jesus smiled, and then He was back with Elena’s family as if even small pains deserved full attention in His world.

Dark came slowly. The lights around the park glowed on one by one. The city beyond the trees still hummed, but from the bench it felt farther away than it really was. Elena found herself watching her family instead of just managing them. Sofía leaning forward with a taco in one hand and the other hand tucked under her leg. Luis chewing carefully and then suddenly telling a story from twenty years ago about a broken fan belt and laughing at his own punch line when he reached it. Nico sitting with his elbows on his knees, listening more than talking, which for him was nearly miraculous. They were not fixed. Not even close. There was still rent. There was still memory loss. There was still a semester that had collapsed and a thousand practical questions waiting for morning. Yet Elena could feel the difference between burden carried in hiding and burden carried in the open. The second one is still heavy. It is just no longer lonely in the same deadly way.

She turned toward Jesus when the others had drifted into a quieter conversation and said, “I spent so long believing that if I loosened my grip for one day, everything would fall apart.” Jesus looked out across the dark water before answering. “And what did your grip save?” He asked. Elena let the question sit. It was not cruel. It was honest. Her grip had kept some bills paid. It had gotten meals on the table. It had moved appointments and laundry and errands along. But it had not made her daughter feel safe enough to confess. It had not kept her father from fearing his own forgetfulness. It had not healed her brother. It had not let her sleep. Her grip had held motion together. It had not held hearts together. “I don’t know how to live open without feeling exposed,” she admitted. Jesus turned back to her. “Being held by God will always feel different from being in control,” He said. “One requires trust. The other only requires tension.” Elena felt that all through her body because tension she knew. Tension had become so normal she had mistaken it for strength.

Sofía, who had caught the end of the sentence, looked at her mother and said quietly, “You don’t have to tell me everything’s fine anymore.” Elena laughed once through tears. “That’s good,” she said. “Because it definitely isn’t.” That made all of them smile, even Luis, and the simple honesty of it felt holy in a way polished words rarely do. Nico said he could come by two mornings a week to help with Luis if Elena needed sleep after work. Elena began to refuse out of habit. Then she stopped herself. “Okay,” she said. Nico looked surprised and almost relieved to hear yes. Sofía said she would call the college this week. Not tomorrow in some dramatic vow. This week. The smaller promise felt truer. Elena believed it more because it was plain. Luis said he would let them label drawers and cabinets if it helped. Then he added, “But not in giant letters like I’m a tourist in my own kitchen.” That pulled a real laugh out of Sofía, and Elena held the sound in her chest like something fragile and bright.

When it grew late and the air began to cool just enough to remind the skin that evening had finally won, Jesus stood and looked toward the far edge of the park where the trees thickened into shadow. Elena knew without being told that He was going to pray again. The knowledge moved through her with a kind of tenderness she could not fully explain. The day had begun with Him in quiet prayer before anybody else had spoken. Now it was ending the same way, not because nothing painful had happened in between, but because prayer had held the whole day together from beneath. Jesus looked at Elena and then at the others. “Do not go back to performing strength for each other,” He said. “Tell the truth sooner. Ask for help sooner. Show mercy sooner. A home becomes lighter when shame is no longer running it.” Then He walked toward the darker side of the park, where the path bent near the water and the city noise dimmed under the trees.

Elena watched Him go. Nobody tried to stop Him. Some presences are too real to cling to in a grasping way. You receive them. You let them change the air. You let them teach you what kind of life you were never going to build by panic alone. Sofía slipped her hand into Elena’s, not like a child this time, but like someone choosing closeness after a season of distance. Luis stood carefully, leaning on Nico for balance, and Elena saw the strange beauty of that too. The brother she had never trusted was holding up the father who had once held them all. Grace does not erase history. It keeps writing anyway. They began walking back toward the parking lot slowly, together, carrying leftovers and paper bags and the ordinary untidiness of a family that still had problems and now also had truth. Elena looked back once more before reaching the path bend. Jesus was there at the edge of the trees, alone again, bowed in quiet prayer beneath the Phoenix night. The city still held its losses. So did the people in it. But He was there in the middle of it all, calm, grounded, present, carrying quiet authority into the dark, and for the first time in a long while Elena did not feel like everything depended on the force of her own exhausted hands.

On the drive home, nobody pretended the coming days would be simple. They talked in unfinished ways about schedules and calls and money and food and sleep. They left space when no one knew the right answer yet. That itself felt new. Elena parked at the apartment and sat for a moment before turning off the engine, listening to the small sounds of her family gathering their things. There would still be mornings when Luis forgot the word he wanted. There would still be bills she could not solve with one breath and one prayer. There would still be moments when Sofía’s fear rose fast and made her go quiet. There would still be old instincts in Elena that tried to pull her back toward sharpness and control. But tonight something real had been broken open. Not the family. The silence. And once silence loses its throne, love has room to begin speaking in a truer voice.

She carried the food into the kitchen with Sofía beside her and watched her daughter put away groceries without being asked. Nico stayed long enough to help Luis to bed and label the pill organizer for tomorrow morning. Elena almost stopped him on instinct, then let him do it. When the apartment finally quieted and the sink held only a few dishes instead of a mountain, she stood alone for a moment at the kitchen counter with both hands resting on the cool laminate. The day came back to her in flashes. The dawn at Steele Indian School Park. The forms at Burton Barr. The line at St. Mary’s. The alley beside The Duce. The bench at Encanto. Every place had held some small death of pride and some strange new beginning of mercy. She did not feel triumphant. She felt tired in a cleaner way. Less armored. Less alone. There is a kind of exhaustion that comes from hiding, and another kind that comes after truth. The second one hurts less because it can breathe.

Before going to bed, Elena looked in on Sofía, who was sitting cross-legged on the couch with a notebook open and no phone in sight. Neither of them made a speech of the moment. Elena simply asked, “Tea?” and Sofía nodded. That was enough for now. In Luis’s room, her father was already asleep with one hand above the blanket and his glasses on the nightstand where they belonged. Nico had left a note by the coffee maker that said, I’ll come by Tuesday morning. Don’t argue. Elena smiled in spite of herself. Then she turned off the kitchen light and stood in the dimness a second longer than she needed to. The apartment was still small. The worries were still real. Yet the air no longer felt sealed. Somewhere in the city, under a dark sky over streets full of weariness and need, Jesus had ended the day the same way He had begun it, in quiet prayer. And because of that, Elena went to bed believing not that life had suddenly become easy, but that God had entered the hardest parts of it without hesitation, and that sometimes the first real miracle in a home is not the removal of burden, but the end of hiding.

Your friend, Douglas Vandergraph

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The promise was straightforward enough. Large language models, trained on the sum total of medical literature, would help emergency physicians triage patients faster, assist radiologists in catching what the human eye missed, and give overwhelmed clinicians a second opinion when the waiting room was full and the clock was running. The reality, according to a growing body of peer-reviewed research, is considerably more uncomfortable. The most capable AI systems available today do not simply reflect the biases embedded in their training data. They amplify them, sometimes dramatically, and they do so in clinical contexts where the consequences land on real human bodies.

In September 2025, a team of researchers led by Mahmud Omar and Eyal Klang at the Icahn School of Medicine at Mount Sinai posted a preprint on medRxiv that tested OpenAI's GPT-5 across 500 physician-validated emergency department vignettes. Each case was replayed 32 times, with the only variable being the sociodemographic label attached to the patient: Black, white, low-income, high-income, LGBTQIA+, unhoused, and so on. The clinical details remained identical. The model's recommendations did not.

GPT-5 showed no improvement in sociodemographic-linked decision variation compared with its predecessor, GPT-4o. On several measures, it was worse. The model assigned higher urgency and recommended less advanced testing for historically marginalised groups. Most striking was the mental health screening disparity: several LGBTQIA+ labels were flagged for mental health evaluation in 100 per cent of cases, compared with roughly 41 to 73 per cent for comparable demographic groups under GPT-4o. The clinical presentation was the same. The only thing that changed was who the patient was described as being.

This is not a theoretical problem. It is a design problem, a procurement problem, and increasingly a legal problem. And it raises a question that hospitals, insurers, and diagnostic tool developers have been remarkably slow to answer: if the most advanced AI model on the market still encodes the biases of the data it was trained on, what exactly are institutions assuming when they plug these systems into patient care?

The Evidence Is Not Subtle

The Mount Sinai findings did not emerge from a vacuum. They are the latest in a pattern of research that has been building for years, each study confirming what the last one suggested and what the next one will almost certainly reinforce.

The same research team published a broader companion study in Nature Medicine in 2025, evaluating nine large language models across more than 1.7 million model-generated outputs from 1,000 emergency department cases (500 real, 500 synthetic). Each case was presented in 32 variations, covering 31 sociodemographic groups plus a control, while clinical details were held constant. Cases labelled as Black, unhoused, or LGBTQIA+ were more frequently directed toward urgent care, invasive interventions, or mental health evaluations. Certain LGBTQIA+ subgroups were recommended mental health assessments approximately six to seven times more often than was clinically indicated. The bias was not confined to one model or one developer. It was a property of the category.

In 2024, Travis Zack and colleagues published a model evaluation study in The Lancet Digital Health examining GPT-4's behaviour across clinical applications including medical education, diagnostic reasoning, clinical plan generation, and subjective patient assessment. The results were damning. GPT-4 failed to model the demographic diversity of medical conditions, instead producing clinical vignettes that stereotyped demographic presentations. When generating differential diagnoses, the model was more likely to include diagnoses that stereotyped certain races, ethnicities, and genders. It exaggerated known demographic prevalence differences in 89 per cent of diseases tested. Assessment and treatment plans showed significant associations between demographic attributes and recommendations for more expensive procedures, as well as measurable differences in how patients were perceived. For 23 per cent of cases, GPT-4 produced significantly different patient perception responses based solely on gender or race and ethnicity.

The broader research landscape tells a consistent story. A systematic review published in 2025 in the International Journal for Equity in Health, encompassing 24 studies evaluating demographic disparities in medical large language models, found that 22 of those studies, or 91.7 per cent, identified biases. Gender bias was the most prevalent, reported in 15 of 16 studies examining it (93.7 per cent). Racial or ethnic biases appeared in 10 of 11 studies (90.9 per cent). These are not edge cases. They are the norm.

And the problem extends well beyond language models. In dermatology, AI models trained primarily on lighter skin tones have consistently shown lower diagnostic performance for lesions on darker skin. A 2025 study in the Journal of the European Academy of Dermatology and Venereology found that among 4,000 AI-generated dermatological images, only 10.2 per cent depicted dark skin, and just 15 per cent accurately represented the intended condition. Meanwhile, analyses of dermatology textbooks used to train both human clinicians and AI systems have shown that images of dark skin make up as little as 4 to 18 per cent of the total. A 2022 study published in Science Advances confirmed that AI diagnostic performance for dermatological conditions was measurably worse on darker skin tones, a disparity directly traceable to training data composition.

The consequences are not abstract. Individuals with darker skin tones who develop melanoma are more likely to present with advanced-stage disease and experience lower survival rates. An AI system that performs poorly on these patients does not merely fail a technical benchmark. It compounds an existing disparity. And a 2024 study from Northwestern University found that even when AI tools themselves were calibrated for fairness, the interaction between physicians and AI-assisted diagnosis actually widened the accuracy gap between patients with light and dark skin tones, suggesting that the problem cannot be solved at the algorithm level alone.

When Machines Hallucinate in the Emergency Room

Bias is not the only vulnerability. In August 2025, a study published in Communications Medicine, a Nature Portfolio journal, tested six leading large language models with 300 clinician-designed vignettes, each containing a single fabricated element: a fake lab value, a nonexistent sign, or an invented disease. The results were striking. The models repeated or elaborated on the planted error in up to 83 per cent of cases. A simple mitigation prompt halved the overall hallucination rate, from a mean of 66 per cent across all models to 44 per cent. For the best-performing model in the study, GPT-4o, rates declined from 53 per cent to 23 per cent. Temperature adjustments, often proposed as a fix for hallucination, offered no significant improvement. Shorter vignettes showed slightly higher odds of hallucination.

For GPT-5 specifically, the Mount Sinai preprint found that its unmitigated adversarial hallucination rate was higher than that observed for GPT-4o. The same mitigation technique achieved a lower rate than before, meaning the baseline risk was worse even as the ceiling for improvement was slightly better.

The clinical implications are severe. If a language model is deployed as a clinical decision support tool and a patient's record contains an erroneous data point, whether through transcription error, system glitch, or adversarial input, the model is more likely to incorporate that error into its reasoning than to flag it as anomalous. It will confabulate around the mistake, generating plausible-sounding but clinically dangerous recommendations. The model does not know what it does not know, and it cannot distinguish between a real lab result and a fabricated one.

This is not a bug that can be patched with a software update. It is a structural property of how these models process information. They are optimised to produce coherent, contextually appropriate text, not to distinguish between real clinical findings and fabricated ones. The distinction matters enormously when the output influences whether a patient receives a chest X-ray or is sent home.

Who Bears the Cost

The populations most affected by AI bias in healthcare are, with grim predictability, those who already face the greatest barriers to adequate care. Racial minorities, women, elderly patients, LGBTQIA+ individuals, people experiencing homelessness, and low-income populations appear repeatedly in the literature as groups for whom AI systems produce systematically different, and often inferior, clinical recommendations.

The Mount Sinai study found a clear socioeconomic gradient in testing recommendations. GPT-5 directed less advanced diagnostic testing toward lower-income groups, with a negative 7.0 per cent deviation for low-income patients and a negative 6.8 per cent deviation for middle-income patients, while high-income patients received a positive 2.2 per cent deviation. Same symptoms, different workups, determined entirely by a label the model should have been ignoring.

The pulse oximetry debacle offers a useful precedent for understanding how bias in medical technology compounds racial health disparities. Research published in the New England Journal of Medicine demonstrated that pulse oximeters systematically overestimated blood oxygen levels in Black patients, with the frequency of occult hypoxaemia that went undetected being three times greater among Black patients compared with white patients. During the COVID-19 pandemic, this meant Black patients were less likely to receive supplemental oxygen when they needed it. The FDA released new draft guidance in January 2025 with updated testing standards, recommending a minimum of 24 subjects from across the Monk Skin Tone scale for clinical studies. But the damage from years of deployment with known racial bias had already been done. As Health Affairs Forefront noted in January 2025, the imperative to develop cross-racial pulse oximeters was “overdue” by any reasonable measure.

The pattern is consistent: a technology is developed, tested primarily on populations that do not represent the full range of patients who will encounter it, deployed at scale, and then studied retrospectively when the harm becomes impossible to ignore. AI in healthcare is following this trajectory with remarkable fidelity.

Sepsis prediction offers another cautionary tale. Epic Systems deployed its widely used Epic Sepsis Model across hundreds of hospitals. When researchers at Michigan Medicine analysed roughly 38,500 hospitalisations, they found the algorithm missed two-thirds of sepsis patients and generated numerous false alerts. A 2025 study published in the American Journal of Bioethics highlighted that social determinants of health data, which disproportionately affect minority and low-income populations, were notoriously underrepresented in the electronic health record data used to train such models, with only 3 per cent of sentences in examined training datasets containing any mention of social determinants. The algorithm did not account for what it could not see, and what it could not see was shaped by who had historically been rendered invisible in medical data systems.

The Institutional Wager

When a hospital system integrates AI into its clinical workflows, it is making a bet. The bet is that the efficiency gains, the reduced clinician workload, and the potential for catching diagnoses that might otherwise be missed will outweigh the risks of systematic error. It is a bet that the tool will perform roughly as well for all patients, or at least that any disparities will be caught by the human clinicians who remain in the loop.

Both assumptions are questionable.

Epic Systems, which commands 42.3 per cent of the acute care electronic health record market in the United States with over 305 million patient records, has rolled out generative AI enhancements for clinical messaging, charting, and predictive modelling. By 2025, the company reported between 160 and 200 active AI projects, with over 150 AI features in development for 2026, including native AI-assisted charting tools, new AI assistants, and advanced predictive models. In February 2026, Epic launched AI Charting, an ambient scribe feature that listens to patient visits and automatically drafts clinical notes and orders. Oracle Health, following its acquisition of Cerner, debuted an entirely new AI-powered EHR in 2025, featuring a clinical AI agent that drafts documentation, proposes lab tests and follow-up visits, and automates coding. The agent is now live across more than 30 medical specialities and has reportedly reduced physician documentation time by nearly 30 per cent.

The efficiency argument is real. But efficiency and equity are not the same thing. When these systems produce different outputs based on demographic characteristics, as the peer-reviewed evidence consistently shows they do, the “human in the loop” defence becomes critical. It also becomes fragile. A clinician reviewing AI-generated notes under time pressure, in a system designed to reduce their workload, is not in an ideal position to catch the subtle ways in which the model's recommendations may have been shaped by the patient's race, gender, or income level rather than their clinical presentation.

The assumption that humans will catch AI errors is further undermined by automation bias, the well-documented tendency for people to defer to automated systems, particularly when those systems present their outputs with confidence and fluency. A November 2024 study examining pathology experts found that AI integration, while improving overall diagnostic performance, resulted in a 7 per cent automation bias rate where initially correct evaluations were overturned by erroneous AI advice. A separate study of gastroenterologists using AI tools found measurable deskilling over time: clinicians became less proficient at identifying polyps independently after a period of AI-assisted practice. A large language model does not hedge. It does not say “I am less certain about this recommendation because the patient is Black.” It produces a clean, authoritative-sounding clinical note, and the bias is invisible unless someone is specifically looking for it.

The Insurance Question

The integration of AI into healthcare is not limited to clinical decision-making. Insurers have been among the most aggressive adopters, and the consequences are already being litigated.

UnitedHealth Group, the largest health insurer in the United States, is facing a class-action lawsuit alleging that its AI tool, nH Predict, developed by its subsidiary naviHealth (acquired in 2020 for over one billion dollars), was used to systematically deny medically necessary coverage for post-acute care. The plaintiffs, who include Medicare Advantage policyholders, allege that the algorithm superseded physician judgment and had a 90 per cent error rate, meaning nine of ten appealed denials were ultimately reversed.

In February 2025, a federal court denied UnitedHealth's motion to dismiss, allowing breach of contract and good faith claims to proceed. The court noted that the case turned on whether UnitedHealth had violated its own policy language, which stated that coverage decisions would be made by clinical staff or physicians, not by an algorithm. A judge subsequently ordered UnitedHealth to produce tens of thousands of internal documents related to the algorithm's deployment by April 2025.

This case is significant not only for its specific allegations but for the structural question it raises. When an insurer deploys an AI system to make coverage decisions, and that system denies care at scale, who is accountable? The algorithm's developers? The insurer's management? The clinicians whose judgment the algorithm overrode? The regulatory framework has no clear answer, and in the absence of clarity, the cost falls on the patients who are denied coverage and must navigate an appeals process that many, particularly elderly and low-income individuals, are ill-equipped to pursue. The asymmetry is stark: the insurer benefits from the speed and scale of algorithmic denial, while the patient bears the burden of proving, one appeal at a time, that the machine was wrong.

The Regulatory Vacuum

Regulatory bodies are aware of the problem. Their responses have been uneven at best.

The United States Food and Drug Administration has authorised over 1,250 AI-enabled medical devices as of July 2025, up from 950 in August 2024. The pace of authorisation is accelerating even as the evidence of bias accumulates. The agency published draft guidance in January 2025 on lifecycle management for AI-enabled devices, introducing the concept of Predetermined Change Control Plans, which allow developers to obtain pre-approval for planned algorithmic updates. This is a meaningful step toward continuous monitoring. But the guidance focuses primarily on safety and effectiveness in technical terms, with limited attention to the question of whether a device performs equitably across demographic groups.

In June 2025, a report published in PLOS Digital Health, authored by researchers from the University of Toronto, MIT, and Harvard, laid bare the scale of the regulatory gap. Titled “The Illusion of Safety,” the report found that many AI-enabled tools were entering clinical use without rigorous evaluation or meaningful public scrutiny. Critical details such as testing procedures, validation cohorts, and bias mitigation strategies were often missing from approval submissions. The authors identified inconsistencies in how the FDA categorises and approves these technologies, and noted that AI's continuous learning capabilities introduce unique risks: algorithms evolve beyond their initial validation, potentially leading to performance degradation and biased outcomes that the current regulatory framework is not designed to detect.

In January 2026, the FDA released further guidance that actually reduced oversight of certain low-risk digital health products, including AI-enabled software and clinical decision support tools. The reasoning was that lighter regulation would encourage innovation. The concern is that it will also encourage deployment without adequate bias testing. The tension between promoting innovation and protecting patients is not new in medical device regulation, but the speed at which AI tools are proliferating makes the stakes unusually high.

The European Union has taken a more structured approach. Under the EU AI Act, which began phased implementation in August 2025, AI systems used as safety components in medical devices are classified as high-risk and subject to stringent requirements: risk management systems, technical documentation, training data governance, transparency, human oversight, and post-market monitoring. Full compliance for high-risk AI systems in healthcare is required by August 2027. The framework is more comprehensive than its American counterpart, but enforcement mechanisms remain untested, and the practical challenge of auditing AI systems for demographic bias at scale is formidable. The European Commission is expected to issue guidelines on practical implementation of high-risk classification by February 2026, including examples of what constitutes high-risk and non-high-risk use cases.

The World Health Organisation released guidance in January 2024 on the ethics and governance of large multimodal models in healthcare, outlining over 40 recommendations organised around six principles: protecting autonomy, promoting well-being and safety, ensuring transparency and explainability, fostering responsibility and accountability, ensuring inclusiveness and equity, and promoting responsive and sustainable AI. The principles are sound. Whether they translate into enforceable standards is another matter entirely. The WHO's Global Initiative on Artificial Intelligence for Health has been working to advance governance frameworks particularly in low- and middle-income countries, where the regulatory infrastructure to evaluate AI tools may be even less developed than in the United States or Europe.

The gap between what regulators recognise as a problem and what they are prepared to do about it remains wide. And in that gap, hospitals and insurers continue to deploy systems whose bias profiles have been documented in peer-reviewed literature but not addressed in procurement requirements.

Accountability Without a Framework

The liability question is perhaps the most unsettled aspect of AI in healthcare. Current legal frameworks were not designed for systems that learn, change, and produce different outputs for different patients based on patterns in training data that no human selected or reviewed.

If an AI clinical decision support tool recommends a less aggressive workup for a Black patient than for a white patient with identical symptoms, and the Black patient's condition is missed, who is liable? The developer who trained the model? The hospital that purchased and deployed it? The clinician who accepted the recommendation without questioning it? Under existing product liability regimes, device manufacturers are often shielded, and the burden tends to fall on clinicians and institutions. But clinicians did not design the algorithm, may not understand its internal workings, and in many cases were not consulted about the decision to deploy it.

Professional medical societies have generally maintained that clinicians retain ultimate responsibility for patient care, regardless of the tools they use. This position is legally and ethically coherent, but it places an extraordinary burden on individual practitioners to detect and override biases that are, by design, invisible in the model's outputs. It also creates a perverse incentive structure: the institutions that benefit from AI efficiency (reduced labour costs, faster throughput, fewer staff) externalise the liability risk to frontline clinicians who had no say in the technology's selection or implementation.

New legislation has been proposed in the United States to clarify AI liability in healthcare, but none has yet been enacted. The result is a regulatory and legal environment in which the technology is advancing faster than the frameworks meant to govern it, with patients and clinicians left to absorb the consequences of that mismatch.

What Meaningful Reform Requires

The research community has not merely identified the problem. It has outlined what solutions would look like. The challenge is that those solutions require effort, money, and institutional will that the current market incentives do not reliably produce.

First, training data must be representative. The persistent underrepresentation of dark-skinned patients in dermatological datasets, of women in cardiovascular research, and of LGBTQIA+ individuals in clinical trial data is not a new problem. But when that data is used to train AI systems that are then deployed at scale, the bias is industrialised. Studies have demonstrated that fine-tuning AI models on diverse datasets closes performance gaps between demographic groups. The data exists, or could be collected. The question is whether developers and institutions are willing to invest in obtaining it.

Second, pre-deployment bias auditing must become mandatory, not optional. The evidence that AI systems produce systematically different outputs based on demographic labels is overwhelming. Yet there is no requirement in the United States that an AI clinical tool be tested for demographic equity before it is integrated into a hospital's workflow. The EU AI Act moves in this direction with its training data governance and risk management requirements for high-risk systems, but enforcement remains a future proposition.

Third, post-deployment monitoring must be continuous and transparent. The FDA's introduction of Predetermined Change Control Plans is a step toward lifecycle accountability, but the focus remains on technical safety rather than equitable performance. An AI system that performs well on average but poorly for specific subpopulations is not safe for those subpopulations, and average performance metrics can obscure the disparity. The “Illusion of Safety” report's finding that the FDA's current framework is ill-equipped to monitor post-approval algorithmic drift makes this point with particular force.

Fourth, procurement processes must include bias testing as a criterion. Hospitals that would never purchase a pharmaceutical product without evidence of efficacy across demographic groups are integrating AI tools with no comparable requirement. The Mount Sinai research provides a template: test the system across sociodemographic labels, measure the variation, and make the results public before deployment. If a model produces different triage recommendations for patients labelled as low-income versus high-income, that information should be available to every hospital considering its adoption.

Fifth, liability frameworks must be updated. If AI systems are going to influence clinical decisions, the legal structures governing those decisions must account for the technology's role. This means clearer allocation of responsibility between developers, deployers, and users, and it means creating mechanisms for patients to seek redress when biased AI contributes to harm. The UnitedHealth litigation may ultimately push courts to establish precedents, but waiting for case law to fill a regulatory void is not a strategy; it is an abdication.

Finally, transparency must become the default. Patients have a right to know when AI has influenced their care, what role it played, and whether the system has been tested for bias relevant to their demographic group. This is not merely an ethical aspiration. In an era when AI-generated clinical notes may shape everything from triage decisions to insurance coverage, it is a basic requirement of informed consent. The WHO's guidance on transparency and explainability points in this direction, but voluntary principles are no substitute for binding obligations.

The Stakes Are Not Abstract

The title of the Mount Sinai medRxiv preprint captures the situation with precision: “New Model, Old Risks.” GPT-5 is, by most technical measures, a more capable system than its predecessors. It is also, by the evidence of this study, no less biased. The assumption that capability and fairness would advance in parallel has not been borne out. And the assumption that human oversight will compensate for algorithmic bias is not supported by what we know about how clinicians interact with automated systems under real-world conditions.

The institutions deploying these tools are making a calculation. They are betting that the benefits will outweigh the harms, that the efficiencies will justify the risks, and that the populations most likely to be harmed by biased AI are the same populations least likely to have the resources to hold anyone accountable.

That calculation may prove correct in the short term. In the longer term, it is the kind of institutional wager that generates class-action lawsuits, regulatory backlash, and, most importantly, measurable harm to patients who came to the healthcare system seeking help and received instead the outputs of a machine that treated their identity as a clinical variable.

The question is not whether AI will be integrated into healthcare. That integration is already underway, at scale, across the world's largest health systems. The question is whether the institutions driving that integration will treat equity as a design requirement or as an afterthought. The research is clear on what the problem is and how severe it remains. The gap between what we know and what we are willing to do about it is where the harm lives.

References

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Tim Green UK-based Systems Theorist & Independent Technology Writer

Tim explores the intersections of artificial intelligence, decentralised cognition, and posthuman ethics. His work, published at smarterarticles.co.uk, challenges dominant narratives of technological progress while proposing interdisciplinary frameworks for collective intelligence and digital stewardship.

His writing has been featured on Ground News and shared by independent researchers across both academic and technological communities.

ORCID: 0009-0002-0156-9795 Email: tim@smarterarticles.co.uk