Not the Hardest Thing We've Done | Salmaan Kamal

Dr. Salmaan Kamal is an internal medicine physician and addiction specialist at the VA Medical Center in West Los Angeles, where he cares for veterans experiencing homelessness. At every major crossroads — leaving Alabama for Princeton, returning home for medical school, turning down an Ivy League fellowship — he chose proximity to need and to family over prestige. In this conversation, we trace that pattern and what it taught him about trusting his own instincts. We talk about what happens when his daughter was born at 23 weeks and how surviving that changed the scale of everything that followed. And we get into the daily discipline of putting the phone away at six in the evening — what that discomfort actually feels like, and what's on the other side of it. Salmaan is one of the most thoughtful people I know. This conversation is about what it costs to stay that way.

---

Salmaan Kamal, MD, was raised in Tuscaloosa, Alabama, and he attended Princeton University with a focus on global health and health policy. After graduation, Kamal worked as a policy associate at the National Coalition on Health Care in Washington, D.C., where he advocated for policy reform that improved value in the U.S. health care system.

Kamal attended medical school at the University of Alabama at Birmingham (UAB), where he led the student-run free clinic for the uninsured. He completed internal medicine residency and chief residency at UAB Hospital, where he completed the Society of General Internal Medicine's Leadership in Health Policy Program. After residency, he completed the UCLA National Clinician Scholars Program, a health services research and public health fellowship. His work focuses on improving care for people with a history of homelessness, addiction, and criminal legal system involvement. He currently cares for people experiencing homelessness at the West Los Angeles VA Medical Center.

For more on some of Salmaan's work: https://youtu.be/VG3R6XNC1Qk?si=_MNIzk2xDRqBMB4J and https://healthpolicy.ucla.edu/our-work/health-equity-challenge/finalists/2024/salmaan-kamal

In this episode:

- Growing up in Tuscaloosa with two physician parents — and the family intervention that sent him to Princeton instead of Alabama
- The moment in the operating room when he realized he was the only one looking at the clock
- A cold email, a twenty-minute walk across campus, and finding his people
- What it means to choose a safety-net hospital over a bigger name — again and again
- His daughter's birth at 23 weeks, and how "this is not the hardest thing we've done" became a family compass
- Putting the phone away at six — what boredom actually feels like, and why productivity was the permission structure to start
- The question he's sitting with now: what happens when the constraint disappears and work becomes optional again
- What he'd build if he trusted himself completelyDr. Salmaan Kamal, MD, was raised in Tuscaloosa, Alabama, and he attended Princeton University with a focus on global health and health policy.

Transcript

THE PRINCIPAL UNCERTAINTY

Episode: "Not the Hardest Thing We've Done" 

Guest: Salmaan Kamal

GEORGE: Uncertainty is sort of the central watchword here — uncertainty and meaning-making. Thinking about the space between achievement and fulfillment. You can remember looking around classrooms at Princeton, or talking to kids who had been on the achievement conveyor belt nonstop, and just — wait, is this really all there is? Some kids hit that in college. Some people don't get there until much later. Part of the work I'm trying to do here — at least the on-ramp to it — is having these conversations with fascinating people like yourself about how you've navigated your own inflection points. I want to hear your story, where you are now, and what questions you're sitting with.

Sal, tell me about your path. How would you describe where you are now, and how'd you get here?

SALMAAN: I can start with now and then talk about how I got here. Right now I'm an internal medicine doctor. I do both primary care and hospital medicine, and I practice addiction medicine. I work in West Los Angeles at the VA Medical Center, caring for veterans experiencing homelessness. Part of my job is clinic-based care, but the other part is meeting veterans where they are — some street medicine, and also meeting veterans who've recently been housed, which is a really unstable time for my patients. Being able to take the time to meet them in their home — on the street, wherever that is — has been really fulfilling. I do clinical care, education, some research. I really love it.

I did not think I would end up here — whether "here" is Los Angeles or primary care addiction medicine — ten years ago. I grew up in Tuscaloosa, Alabama. Both my parents were private practice physicians. My mom, an interventional cardiologist — very busy, very hands-on work. My dad, an endocrinologist — also busy, but more cerebral, fewer procedures. I always had an eye toward medicine because I liked the idea of service. I saw how respected my parents were in our community. I saw that they seemed fulfilled. I liked science, I liked math. I had medicine in my sights since middle school.

When I went to college at Princeton, it was a big culture shock. Up until the day before the enrollment deadline, I'd planned to go to the University of Alabama. They'd offered me a very large scholarship — full tuition plus a living stipend, generous, ten minutes from my parents' home. I had close family friends who'd gone there. I was close with my parents and my sister. A lot of things were pulling me there.

But I had an itch to leave the state. I had verbally committed to Alabama when my parents and sister staged what I'd call an intervention — the day before the Princeton deadline — and said: who are you doing this for? Where do you want to go, in a vacuum, without us? And I said: I probably want to leave the state, try something new, go to Princeton. They were very supportive. So I enrolled.

It was hard to be away from family. Hard for me, but harder for them.

At Princeton, I was pre-med, still had medicine in mind, but started exploring other things — global health, anthropology, public policy. I did some global health work, some domestic health policy work, and really broadened from clinical medicine to clinical medicine plus systems improvement, research, figuring out how medicine intersects with public health and health justice.

After Princeton I worked for a year in health policy in DC at a small nonprofit called the National Coalition on Healthcare. I wanted to see if I'd be happy working full-time in policy — leaving clinical medicine, focusing on research. It was good. I enjoyed it. But I missed the science, and I missed clinical practice.

So I went back to medical school — back home in Alabama, which was great, though I was nervous at first. I'd always assumed the most prestigious training sites were the best training sites. I went to UAB, wondering if I'd regret not going somewhere my Princeton classmates had gone — Harvard, Columbia. But I really loved my time at UAB. I was close to family — that mattered deeply, especially as my grandmother got older and passed away. I met my now-wife at UAB, second year of med school. And there was something about developing my clinical skills in the South, being able to care for patients who weren't far from where I grew up, that was important to me in a way I hadn't expected. Beyond proximity — the need in the South compared to other parts of the country is enormous. My home state still hasn't expanded Medicaid. All of that came together into a really meaningful time.

I chose to stay at UAB for internal medicine residency, despite offers at bigger-name programs in the Northeast and on the West Coast, because my then-girlfriend — now wife — was still at UAB doing her MD-PhD. And because I loved the hospital, I loved working with that population. UAB is a true safety net hospital. If we didn't provide the care to the patients who lived around that hospital in Alabama, no one would.

Great clinical training. Great friendships. Got married. First kid.

When I finished residency I still had an eye toward policy and systems change. The clinical training was fantastic, but I was searching for mentorship around changing systems in public health. I found and then went to the UCLA National Clinical Scholars Program — historically called the Robert Wood Johnson Fellowship — which trains health providers in health systems change: implementation science, community-based participatory research, advocacy. I did two years there, working in the LA County jail system doing addiction medicine. And now I've recently transitioned to the VA. That's how I got here.

GEORGE: Thank you. I'm struck by a few things — there's a real cadence to your leaving Alabama and then returning, the world you've built for yourself now. How has your notion of home changed?

SALMAAN: Home has always been Alabama. It's hard for me to see that changing, given that my parents and family are there, my wife's family — we're both from there, we got married there, our first kid was born there.

Home will always be Alabama. It feels different now as we've moved around the country. We're actually in Alabama right now — I live in Los Angeles, we're visiting. Coming back to our parents' houses, to the med school campus where we met, seeing old mentors — it's like walking into a time machine. Some things haven't changed at all. Some things feel alien because they've changed so much.

It's always been Alabama. It just feels different.

GEORGE: When you think about your trajectory — there's a real beauty in having had that clarity about medicine from middle school on. But within that frame, there have been dramatic shifts. The policy work, addiction medicine, working with incarcerated folks, now the VA. What were the key inflection points?

SALMAAN: One of my first inflection points was realizing I didn't like the operating room. That's a big one for anyone in medicine — are you going to do procedures, or aren't you? I went into medical school thinking I'd do surgery. I liked engineering, I was decent with my hands, I had mentors in that space.

The first thing I noticed in the OR: I was the only person looking up at the clock. Everyone else was completely locked in.

GEORGE: That's a data point.

SALMAAN: It's a data point. When I realized I wasn't going to be a surgeon, I started searching for mentors in other fields. One of them was Stefan — he runs a podcast now, actually. He was well-known at UAB, busy, hard to get on his schedule. I cold-emailed him. He wrote back: my schedule is completely booked, but I have a twenty-minute cross-campus walk at this time — if you want to walk with me, happy to talk.

We talked about Princeton, about how I'd ended up at UAB, about his own path from Harvard to UAB and how meaningful that move had been for him, about his work caring for people experiencing homelessness in Birmingham, his addiction medicine work, how he'd tied research to advocacy, consistently engaging with people at the local and state level on policy. In that conversation I felt like I'd found my people. He became an active mentor and connected me with others. That was a major inflection point.

Another: the decision to stay at UAB for residency. I almost left. I talked seriously with my parents and my then-girlfriend about where we'd go. We'd seriously considered other programs. Toward the end, I decided I really wanted to stay. It wasn't an inflection point about the type of medicine I'd practice — I already knew I was probably headed toward primary care, addiction medicine, public health, advocacy. It was more about how I was going to balance happiness, proximity to family, career opportunity. I don't know what would have happened at a different residency. I probably would have been fine. But staying, being closer to family as they've gotten older, building a family of my own — I think that was an important decision.

GEORGE: What's another place that's shown up?

SALMAAN: Medicine has a kind of standardized inflection point every three to four years, because you have to pick where you go next. So going to UCLA — where rates of homelessness and incarceration are much higher — with an opportunity to work in a jail system, to learn about and improve jail diversion programs and addiction medicine programs in the community.

As I've gone through this process, I've been developing more of an ethical framework that makes sense for me — figuring out what I think is important work, what I can actually be good at, how my skillset and background can best improve care. It has landed in addiction medicine, primary care, homeless healthcare. Really seeing patients and trying to build systems that save people's lives as they transition in and out of carceral institutions, as they move from unhoused to housed and back.

As I've gotten clearer on what I'd be good at and where I'd have the most impact, the decisions have gotten clearer too. Part of it was growing confidence in my own instincts. Part of it was finally understanding what I actually wanted.

GEORGE: Yeah, that makes total sense.

SALMAAN: The last thing I'll say — and this is transitioning to the personal — is my first daughter. She was born quite premature, at 23 weeks. She's doing great now. I hope you can't hear her yelling and bouncing around downstairs.

But at the time — kids born at 23 weeks, roughly one in two don't make it out of the hospital. That period was trying in so many ways: trying to be a parent, being a husband, a son, managing all of those relationships, managing the uncertainty, trying to stay positive but realistic, trying to understand what I needed from other people and what other people needed from me.

When my wife and I and our families made it through that, everything else seemed a lot easier. A lot of luck was involved. But now, when something comes up at daycare or school, Sushma and I look at each other and say — this is not the hardest thing we've done. Our son got sick on the plane and threw up in the car. This is not the hardest thing we've done. It's going to be fine.

That probably made it easier to make decisions, too.

GEORGE: Nothing like that kind of perspective. You've been, for as long as I've known you, an intensely reflective person — always thoughtful, always connecting the dots. Are there particular relationships, contexts, or spaces you've found especially conducive to doing that work? The work of suturing specific moments to a larger framework?

SALMAAN: I journal fairly regularly — most days of the week. I try to incorporate mindfulness into my daily routine, although my mindfulness sometimes looks like: I'm exhausted, I'm on the couch, maybe I'll meditate for a few minutes. I meditate right into a nap.

GEORGE: Right on.

SALMAAN: Writing helps me the most. Journaling, I do at the end of the day when the kids are asleep and the house is quiet. I've never accomplished everything I wanted to accomplish in a day from work, but I'm learning to try to hard stop at five and just live my life until I go to sleep.

Something about nighttime, quiet, kids asleep, day already survived — I want to do something. I try to do it without a screen, onto a notebook. Sometimes onto a phone or laptop depending on what I'm writing. That's been the most helpful practice for connecting the dots.

Conversations with friends like yourself. Mindfulness.

And one thing I've been trying to do is get more comfortable with boredom and my own thoughts. It sounds silly, but it's genuinely hard. I find myself reaching for my phone, so I put it in the bedroom. Then I find myself reaching for my AirPods — this is a good time to listen to a podcast, right? I scroll through and I don't want to listen to any of it. I just don't want to be by myself. But when I'm on a drive and decide to leave the phone away, roll the windows down, just drive — that's helpful. Go on a walk.

GEORGE: What's the texture of that like? I want to use the word "unclenching" — around the moment when you realize you're chasing the relentless pursuit of adequate distraction. I don't know what I'm scared of in the moment of silence, but if you were watching from orbit it would seem like I'm deathly afraid of not having enough distraction. What's that like for you now, when you let yourself actually be in it?

SALMAAN: It's uncomfortable at first. What I try to do now is put my phone away as quickly as I can on weekday evenings — charge it in the bedroom. I'm not always good at it. Sometimes I put on music. Sometimes I leave the house quiet and just be with the kids, get ready for daycare the next day. The habit of doing that every day helps, because there's still something to do. I'm still interacting with my family.

Then when the kids go to sleep, there's this discomfort again. I could get my phone — everyone's asleep, it's not too late, I could check email, I could doom scroll. But on the days when I'm able to stay away from it from six in the evening until the next morning — there is a point, I'm not sure exactly when, when the discomfort passes.

The texture changes. From me being uncomfortable with me. It's not total clarity. There are still thoughts bouncing around, jumbled. But at least I notice what's there, and I can sit with it longer.

GEORGE: Habits is such an interesting word in this context. On its face it's self-evidently clear — you're talking about cultivating habits of attention. But the actual moment where I'm trying to flip the switch from A to B, knowing that if I do this every day for a month it'll be easier — right now it's still hard.

SALMAAN: Still learning. I'm not great at it every day. But what I've noticed as I've done it more: things slow down. I notice what's moving through my mind.

It's interesting, because I started doing this as a productivity tool, honestly. I thought if I disconnect from electronics, maybe I'll sleep better, be more productive the next day.

GEORGE: Is productivity like a permission structure for you?

SALMAAN: Yeah. A hundred percent.

And as I've done it more, maybe it's helped my productivity in some ways — I'm more comfortable being away from my phone, and that probably helps. But it's become something different. There are times when I feel satisfied just being alone. Sitting. Doing dishes. Getting the kids' bags ready for tomorrow. Lying in bed knowing I probably won't sleep for fifteen or twenty minutes, and just thinking back: hey. Today was a good day. It's not a small thing, that today was a good day. That's been really valuable.

GEORGE: Does it feel like an act of discipline to you, or would you describe it differently?

SALMAAN: Others would call it discipline. I'd call it planning.

I consider myself fairly disciplined, but if you asked me to do something important at my desk with my phone face up versus with my phone on do-not-disturb in a cabinet across the room — those are very different work sessions. I don't think it's all discipline. It's just thinking about the conditions.

And I hate turning this into productivity hacks, but: telling Sushma what I was trying to do, asking if she wanted to do it with me. After we FaceTime our families, right before dinner, we put our phones away and try not to touch them again. Having a partner in it helped.

There was also a moment of shame — Sadia, our oldest, started noticing that we were always on our phones and wanting the phone herself. We couldn't tell her not to want it when we were always on it. That was more stick than carrot.

Some of our happiest times together have been hiking and camping — completely disconnected. The first day is always the hardest, the second day is better, and then by day three or four it's magical. Everything you need is on your back. We started thinking: how do we recreate some of that at home?

Step by step. Not everything at once. Like running — once you start to see the benefits, it becomes easier to keep going.

GEORGE: What is the question you're sitting with now?

SALMAAN: The age-old question of how to best spend my time on the things that matter most to me. Family, kids, wife, parents, taking care of myself — and some part of the time, my work. What does a good life actually look like, and what's the right balance between those things? That's the main question I'm sitting with.

GEORGE: What do you think would shift if you had clarity on that?

SALMAAN: I'd probably work less.

GEORGE: That came quick.

SALMAAN: Yeah.

My wife is a resident, as you know — eighty hours a week. These past two years have been a blessing because I've been the primary parent. I went from being the one who worked eighty hours a week, grinding before work and after work, to being the one who does drop-off and pick-up, takes the kids to appointments, is home with them solo on the weekends when Sushma is on call. It's been a big change of pace. It's been great. And it's hard for me to imagine a time when that isn't the case.

But it will change. Sushma will finish residency. We'll likely move closer to family — we have no family support in Los Angeles right now. We'll split childcare duties. And I know exactly what I know about myself: when that time gets freed up, my instinct will be to work more. Because that has always been my instinct.

There's value in that. I like to think of myself as working in the public interest. More time in my job probably means more people I can engage with and care for. That's valuable.

But I'll lose something important if I'm not intentional. Right now I have no choice. And the thing is — I acknowledge this is such a magical time, especially at their ages. It's the dream. But it's so interesting that I already know myself well enough to know: as soon as I get the green light to work more, I will. Unless I actively choose family life instead.

Maybe that's why I answered so quickly. I know that moment is coming, and I wonder how I'm going to respond to it.

GEORGE: What are you loyal to that you didn't choose?

SALMAAN: I didn't choose my parents. I'm loyal to them. Same with my sister, my family broadly.

I've never been asked that question before.

In some sense, I'm loyal to my patients — whoever walks in the door. Working in correctional settings, with patients who've made mistakes as we all have — if they're my patient, I'm going to advocate for them, full stop. Though I suppose that's a choice I've made, to work in that space and practice that way.

And I'm loyal, to some extent, to my background and heritage. I didn't choose being of Pakistani Muslim descent. I'm quite secular. But I put real time into learning the language, teaching my kids the language, learning the culture and history from my parents with the intention of passing it on — even though I didn't have to.

Those are the two biggest ones. Family. Heritage.

It feels right. From an emotional standpoint, it feels good. And I think there's value — for me and for my kids — in automatically feeling like you're part of something greater. Something that can be comforting, whether or not they ultimately claim it.

GEORGE: What's the difference between uncertainty you can tolerate and uncertainty that paralyzes you?

SALMAAN: I'm not sure this metaphor will land, but — yesterday, with my daughter. She's four, getting more independent. We're trying to find the balance between letting her explore and climb and get her scrapes, and keeping her safe. Something we've started doing, that we got from other parents: Sadia, as long as we can see you, you can go wherever. As long as we can see you and you're not about to jump out of a tree, it's probably fine.

That's the first thing that came to mind when you asked, because it's the same logic. Taking a risk, facing uncertainty — it's tolerable to me as long as, from some imaginary vantage point, I can still see a reasonable path. To me caring for patients, working in the space I want to work in, improving care for the populations I care about. If it's within eyesight — even with real uncertainty — I'm much more comfortable.

And I'll say this as a strength, though it might also be a weakness: I'm a fairly conservative, risk-averse person by nature. If I venture somewhere I can't see a reasonable path forward — can't see the outlines of the life I have now — that's when it becomes paralyzing.

There are spaces farther from direct patient care that could have very large impact. Entrepreneurship, global health, working outside the US — things I've thought about. But it's hard for me to see not just what the work would look like, but what the family life would look like. And that's when I lose my footing.

GEORGE: Connect the dots between risk and uncertainty for me.

SALMAAN: When I think about uncertainty, the first thing that comes to mind is career decisions. How much uncertainty is there in a given path? What will the outcome look like in five years?

If I'm working at a health department, a jail health setting, a housing program doing primary care and addiction medicine — I have a pretty good idea of what five years of committed work will produce. I'll help a lot of people. It might not be transformational at scale, but it will be meaningful. Lower uncertainty, lower risk, clear enough path.

The other example — and I'm not saying I see myself going here, but it fits the metaphor — something like working in health tech, AI-driven health improvement. I'd be committing five years to something that could be quite meaningful, but with high uncertainty. I might see very few patients. The product might fail. I can't see the outlines from where I'm standing. That's the paralyzing kind.

GEORGE: So if you could trust yourself completely right now, what would you do?

SALMAAN: I would build systems.

Citywide, countywide. Systems of high-quality professional healthcare and transitions of care in places where they don't yet exist — or where they exist but are severely underfunded because of the lack of Medicaid expansion. The Deep South.

That feels like some of the most meaningful work I could be doing. And it fits with everything I want: to be a real presence for my family, to be around my kids, to not have to move them out of the country.

GEORGE: Those are my questions for today, brother.

SALMAAN: Thank you.

GEORGE: I so appreciate it.

[END OF TRANSCRIPT]