Dr. Ryan Sultan

I see somewhere around eighteen outpatient visits in a clinic day. Eighteen mental status exams. Eighteen risk assessments. Eighteen medication decisions, most of them quietly consequential. And until recently, none of the software in the room knew what any of that meant.

The clearest version of the problem looked like this: I would finish clinic on a Friday with fourteen notes unwritten. I would carry them home. I would write them after my kids were asleep. Sometimes I would catch myself, at eleven at night, trying to reconstruct from memory whether a patient's affect had been constricted or merely flat. That is not how a careful note should be produced. That is the inevitable consequence of asking a clinician to be a present human with a patient and a typist for an insurance company at the same time.

I tried the ambient scribes. Several of them. They were impressive at capturing what a primary-care visit sounds like — chief complaint, review of systems, plan. What they could not do, in any version I tested, was capture a psychiatric encounter. One of them produced a note from a forty-minute medication-management visit and omitted the mental status exam entirely. Another inserted the phrase “patient denies suicidal ideation” into a section where I had not, in fact, asked. The transcription was accurate. The clinical document was not.

Around the same time, I was working in my research lab on a different problem: how to bring the relevant evidence to the moment of a clinical decision, instead of asking the clinician to do the synthesis in their head. The evidence for pediatric ADHD with comorbid anxiety, for instance, is unambiguous. It is also, in practice, almost never applied evenly. Most clinicians do not have time during a twenty-minute visit to look up the recommendations from a specific RCT in Google Scholar. I wanted the evidence to show up where the decision is, not in a journal six months later.

At some point those two problems became one problem. The note and the evidence are not separate artifacts. They are the same cognitive workflow, written down. So Sigmund is built around that workflow: he sits in on the session, watches the MSE, weighs the differential, drafts the note, and holds the citation chain — all in the same draft. The clinician signs it.

The underlying thesis is small and stubborn: psychiatry deserves software built around its actual cognitive work, not adapted from a primary-care template. That is the only thing Sigmund is trying to do.