I had the opportunity to synthesize my experience with and research on telemedicine into a Grand Rounds presentation at Highland Hospital in Oakland, California on March 11th, 2022.
Copyright Omar Metwally, MD.
I had the opportunity to synthesize my experience with and research on telemedicine into a Grand Rounds presentation at Highland Hospital in Oakland, California on March 11th, 2022.
Copyright Omar Metwally, MD.
By: Omar Metwally, M.D.
To illustrate the utility of cryptography and peer-to-peer networking in protecting the authenticity, integrity, and availability of information.
1. Information is the useful synthesis of data.
Our email inboxes, phones, and hard drives are constantly filling up with data; however, collecting, organizing, and archiving the useful nuggets of information in an ocean of junk requires time, money, and energy. The number of useful emails in my inboxes is a small fraction of the total number of emails, which are mostly spam. I don’t pay for extra storage out of principle. Why fund a company whose spam filters are more likely to block important emails than spam? Why perpetuate the problem?
Similarly with the high-resolution photos which take up so much memory on my phone and hard disk: most of these photographs do not deserve the 2+ MB of memory they occupy on my phone and PC. I’ll commonly snap a photo of a beautiful landscape, a critter I encounter on a walk, or something I need to remember for a short period of time (for example, where I parked). Backing up every photo and video on my phone seems wasteful considering that, like my email inbox, only a small proportion are media that I actually want to preserve. The alternative, however, would be to manually go through each of my inboxes and every photo I take on my phone and make a conscious decision whether to keep or delete a file. This latter strategy often proves far too time-intensive to pursue on a consistent basis.
2. Data that exists in only one location is as good as gone.
I once asked a colleague how he backs up his digital information. “I’ve never needed to back up my data,” he answered. This is a fallacy. Every possible failure of a digital system will eventually and inevitably occur. Hard disks fail all the time. People accidentally delete and lose files. Important bits of information drown in oceans of spam and junk, to the extent that locating them becomes practically impossible. Networked systems get hacked. People lose or upgrade their phones and change platforms, only to realize years later that they never backed up their old Android or iPhone which is now resting in a landfill.
Preserving information in a way that facilitates future retrieval requires:
– a consistent schema for organizing files and directories
– multiple physical (e.g. HDDs and SSDs) and cloud-based storage systems
– a consistent version control schema
– consistency in backing up information to each of these media
In other words, if you really cherish your data, you need to be organized, anticipate what can (and inevitably will) go wrong, and back up consistently. If it’s important information, chances are you’ll also want to encrypt your disks in a way that prevents unauthorized parties from accessing the data, without accidentally losing access to your own data.
3. Cryptography is arguably one of the most useful and powerful technologies in modern-day computing.
Modern cryptography is the basis for digital tools that protect the authenticity and integrity of information. While information ends up in the wrong hands all the time, encryption ensures that only the intended recipient can “unlock” the information. To lay people, “encryption” may conjure messaging apps designed for protect one’s privacy. However, another compelling use case of cryptography, which may be unknown to lay computer users, is to mathematically prove the authenticity of digital information. Algorithms such as SHA256 [https://csrc.nist.gov/glossary/term/SHA_256] can generate a mathematically unique string of numbers and letters, which can serve as a “fingerprint” for a file’s authenticity. Altering even the slightest letter in a document changes this cryptographic fingerprint.
Just like no two individuals have the same fingerprint, so do non-identical files yield unique cryptographic hashes. For instance, an attorney who needs to ensure the authenticity of a collection of evidence can use a cryptographic hashing algorithm such as SHA256 to prove beyond a doubt that the data do indeed represent what the attorney claims they do. However, it’s important to note that these hashing algorithms do not necessarily preserve the actual data to which they refer. It is still upon the attorney to back up the evidence in a secure and redundant manner. Furthermore, the attorney must ensure that each backup is identical. Although a small discrepancy may or may not be consequential in court (for instance, accidentally adding a space, period, or comma may or may not alter the interpreted meaning of a document), the cryptographic hash will be altered, negating the utility of the hashing algorithm.
4. Distributing and decentralizing information is a key value proposition of blockchain networks
Encryption and hashing preceded cryptocurrencies. Hash functions, which are defined by the National Institute of Standards and Technology, are generally free to use and are accessible via command line on any computer. Arguably the biggest value proposition of blockchain networks, on a technical level, is their capacity to add verifiable and tamper-proof timestamps to cryptographic hashes, by propagating a verifiable and identical chronological database across numerous peers around the world. Being able to reliably exchange information with thousands of computers across the world, spanning many different geographic areas, yields redundancy that would be implausible to replicate by entrusting any one party to create thousands of backups, spread them around the world, ensure that they can be accessed reliably, and also ensure the integrity of the original information. In reality, governments restrict access to online content all the time. People in affected locations can use tools such as VPNs to try and circumvent these limitations, but as long as a critical number of nodes is online, the information will not be lost, even if it is inaccessible from a certain geographic region due to inability to run a p2p client.
Cryptocurrencies create financial incentives for people to volunteer hard disk space, broadband, their time, skills, computing resources, and energy to contribute to a peer-to-peer network. Rather than relying on one party to ensure the integrity, authenticity, and availability of data (which is typically hosted in a relatively small number of geographic locations), blockchains are essentially distributed databases (also known as “distributed ledgers” when used in the context of exchanging digital value).
5. Ensuring information availability is another value proposition of blockchain networks
I have been experimenting with IPFS (“InterPlanetary Filesystem” [https://ipfs.io/]), a peer-to-peer file-sharing networking, since 2017. Each byte stored directly on a blockchain network is relatively expensive. While all blockchains are peer-to-peer networks, not all peer-to-peer networks are blockchain. IPFS, an example of a peer-to-peer network that is not a blockchain, allows users to easily upload directories and files to the network, where they are relayed from node to node. IPFS itself is free to use; that is, there is no subscription fee to cover hosting costs because volunteers around the world share in hosting the data. However, this utopian dream of “share everything, preserve everything” ignores the reality of the cost of hosting data. Bandwidth, disk space, processing power, and electricity cost money. Data hosted on IPFS can be “pinned” using a 3rd-party service, but this crosses the line of decentralization and places trust in a 3rd-party service to ensure the persistence of these data. Furthermore, it’s unclear to me why a 3rd-party service would volunteer their resources freely without charging a hosting fee.
Filecoin is a cryptocurrency developed by the creators of IPFS (Protocol Labs) which aims to solve this missing economic incentive. The Filecoin protocol aims to incentivize miners (people with a lot of computing power and storage capacity) to host others’ data by rewarding them with the Filecoin cryptocurrency in exchange for running software that can mathematically prove that the hosted data (1) exist on their hard drive(s), and (2) can be retrieved by the party that is paying Filecoin in exchange for their data to be hosted.
I downloaded the Filecoin client (“Lotus”) and spent several days running IPFS and Lotus in parallel in order to see if hosting a 113 MB file on Filecoin was a better alternative to using traditional cloud servers, and also to learn about the economics of the Filecoin ecosystem. I provide here my impressions of this limited experience without a recommendation for or against any cryptocurrency.
It took me a few hours to sync the Filecoin mainnet to completion. I had to download a snapshot of the chain in order to sync, and I could not locate a SHA256 checksum of the snapshot used to sync. I was unable to sync by connecting to peers directly. Using snapshots hosted on a centralized server which are not associated with published checksums is never best practice because there’s otherwise no way to ensure the authenticity or integrity of what one thinks they are downloading.
The Slack channels used by the Filecoin community are active, and I received timely answers to my questions by knowledgeable contributors. Once the Filecoin chain was synced, I proceeded to upload a 113 MB file using its IPFS hash (that is, the file was already uploaded to IPFS, and I used the IPFS hash to point to the data). The process of uploading data generally entails (1) identifying storage providers (miners) who are willing and able to host one’s data; (2) uploading the data to the storage providers; and (3) paying a transaction fee to upload the data. These transactions are referred to as “deals” and can range from 180 to 540 days in duration. Miners can specify parameters such as the minimum and maximum file size they are willing to host, duration of hosting, and their cost per Gigabyte per time period (in the case of Filecoin, per 30-second epoch). Retrieving data involves a separate set of processes, but I haven’t yet made it that far.
In Filecoin, miners host others’ data, which may or may not be encrypted. This is a potential legal gray area because miners generally don’t know what they’re hosting, and miners are often located in jurisdictions separate from the party seeking hosting services. Deals can be arranged on a Slack channel or third-party reputation marketplaces, but rarely does one know whom exactly they’re dealing with. What happens if a party is uploading content that is illegal in their jurisdiction? Or perhaps legal in their jurisdiction but forbidden in the miner’s jurisdiction?
The process of trying to host data on Filecoin is far more complex than using traditional cloud servers. The average person is unlikely to succeed without a strong commitment to the steep learning curve involved in using these command-line tools. Some of the complexities can theoretically be simplified using third-party services, but this can potentially negate the advantages of using an incentivized p2p network in the first place.
The Filecoin protocol incentivizes miners to contribute their computing resources (and time) to host others’ data by rewarding them for reliably hosting others’ data and financially punishing them by deducting penalties from the collateral they have to put up. Due to the relatively early stage of development of these tools, Filecoin documentation recommends making multiple deals with up to 10 different miners to ensure the availability of one’s data, in case one or more miners’ do not make good on their deal.
On my first attempt to upload a 113 MB file, the “deal” failed for unclear reasons, despite my attempts to troubleshoot the Lotus client’s behavior with the help of technical support volunteers. My starting balance was one Filecoin (1 FIL). Here are some numbers central to the (failed) transaction:
Initial wallet balance: 1 FIL
Cost of hosting 113 MB file with a particular miner for 180 days: 0.01296 FIL ($0.225504, at an exchange rate of $17.4 per FIL on March 12th, 2022).
Wallet balance after the escrow funds were returned to my wallet (i.e. after the deal failed):
Difference between initial and final wallet balance = amount of “gas” burned (network transaction fees):
Therefore, 51.285% of the original proposed cost of hosting the file (0.01296 FIL) was burned in the form of gas. In other words, 0.006646556300701767 FIL / 0.01296 FIL = 0.5128515664121734
While the amount of burned gas may seem trivial, it accounts for a majority of the cost of the failed deal (51.285%)! If the goal is to establish 10 deals with 10 different miners, then the cost of gas associated with failed deals can quickly add up.
6. Mathematical proof of data availability may or may not be necessary
There are certainly cases in which it’s necessary to prove mathematically not just the integrity and authenticity of data (for example, using hashing functions such as SHA256), but also the availability of the data. Filecoin aims to mathematically prove both the existence and availability of data hosted on a peer to peer network while incentivizing miners to uphold deals with parties who need data hosted. However, there are also many instances where a SHA256 checksum uploaded to a blockchain with an immutable timestamp is more than sufficient. In this latter case, the responsibility of organizing, archiving, and maintaining identical copies of these data falls upon the party willing to pay for the weight of this proof. As mentioned above, there are instances where entrusting miners to store and deliver content may be undesirable for legal reasons, privacy, or simply the need to trust that at least one miner with whom one conducts a deal will uphold their end of the deal.
In conclusion, cryptography and peer-to-peer networking are powerful technologies that can help protect the integrity of information and ensure its persistence. Various blockchain networks use financial incentives in different ways to provide a variety of value propositions to network participants. Clearly understanding one’s goals as the relate to information preservation/exchange, and clearly understanding each network’s value proposition, is key to making good investments of one’s time and resources.
By: Omar Metwally, MD
Objective: To illustrate ViaSat, Inc‘s predatory business practices and warn other potential victims.
Hi ViaSat. You stepped on me thinking I was a tiny ant, like all the other tiny ant customers you are stepping on. The truth is, I’m a barbed hook.
July 2020: The pandemic is striking with full force, and I am working 100-hour weeks volunteering in COVID-19 medical units overflowing with very sick patients while completing a Federally-funded research project. Fast forward to March 2022: the world is recovering from the pandemic, and I am getting harassed for the first time in my life by debt collectors trying to collect bogus debt on behalf of ViaSat, Inc.
During my last few months as Principal Investigator of Logisome, Inc’s Federally-funded research project, I signed up for a satellite internet service called ViaSat back in July 2020. The satellite dish was installed on the roof of my home, where I was conducting my responsibilities as PI and volunteering as an Internal Medicine Physician in overflowing COVID-19 medical units.
A technician arrived on Thursday, July 16th, 2020, and installed the satellite dish and equipment. I asked the technician to stay and make sure that the internet connection worked before leaving, but he insisted on leaving immediately. The internet speeds were initially so slow that it felt like a blast back to the 1990s. They were too slow to even load ViaSat’s homepage to look up their customer support phone number — and far too slow to conduct any sort of telemedicine.
I called ViaSat’s customer support in order to solve this internet speed problem and was on the line for nearly 2 hours after the installation trying to troubleshoot extremely slow speeds. The ViaSat technical support person remotely reset my modem, after which point I immediately and permanently lost all access to the internet.
After several hours waiting on hold, escalating emails to ViaSat’s management, and a complaint filed with the Better Business Bureau, they finally agreed to cancel service. I received written assurances that all fees in the contract had been waived and that my service was canceled. They sent me a UPS return label, and I sent back their equipment.
Now I’m receiving text messages from a debt collector saying that my ViaSat account has been sent to a debt collection agency called Halsted Financial. ViaSat did not send me any communications at any point claiming any debts owed to them. Here is one of numerous texts I’ve received from a party claiming to be a debt collector.
Why is the U.S. government (FCC) funding a predatory company that does not deliver what they promise, that wastes people’s resources, and that inflicts harm on hard-working individuals with better things to do than deal with bogus debt and the financial and legal damages resulting from these disreputable business practices? How is this company still in business???
ViaSat touts itself as a reliable internet solution for hospitals and the military. But if you can’t trust the company for submitting your kids’ online homework, why should ViaSat be trusted with people’s lives, health and safety? If you are considering signing up for ViaSat, chances are you live in a remote or undeveloped area in the United States. If you have any other choice of internet service provider, be assured that these alternatives are likely better options. If you have to decide between ViaSat and having no Internet connectivity, then be assured that you are probably better off without Internet.
ViaSat is not a legitimate company that earns a livelihood by selling useful services to customers. Rather, it is a shell of a company hiding the scam that it is: crooks that make money buy fooling people into contracts, breaking their own agreements, and inventing bogus debts so that debt collection agencies can do their dirty work. It is a disgraceful farce.
If you are one of countless victims of ViaSat’s fraudulent business practices, I urge you to call a lawyer and take legal action. A class action lawsuit is ripe for filing. Do not trust a company that lies to resolve BBB complaints, only to spin up bogus debts and send innocent people to debt collection agencies years later. Let’s use all legal means available to us to show this sham company that we are here to collect and make them shed what they owe.
Update on 3/14/2022:
Despite the fact that the service agreement (signed excerpt above) was between ViaSat and Logisome, Inc, ViaSat is fraudulently attributing fictional debt to me as an individual. This was an agreement between two companies. At no point did I conduct business with ViaSat as an individual or enter any agreements with them as an individual. Yet despite these facts, they are damaging my personal credit.
To: Omar Metwally
Date of Correspondence: April 25th, 2022
This ticket (#5338127) has been updated.
Here is the response we received from your carrier.
FCC Consumer Complaints
Federal Communications Commission
Consumer & Government Affair Bureau
Consumer Inquiries and Complaints Division
445 12th Street, SW
Washington D.C. 20554 Response via FCC Electronic Response Program
Re: Omar Metwally, Complaint Ticket No. 5338127
To Whom It May Concern:
Thank you for bringing Mr. Metwally’s complaint to our attention.
The Customer Agreement, signed by Mr. Omar Metwally on July 16, 2020, advises that customers are responsible for returning Viasat’s modem and transceiver within 30 days after disconnection. Failure to do so will result in an unreturned equipment fee of $300.00, not including taxes. Viasat supplies customers with a UPS box, prepaid return shipping label, and illustrated instructions within a week after disconnection.
On August 20, 2020 a bill of $159.00 for an unreturned transceiver generated. No payment was processed resulting in a past due balance.
Mr. Metwally contacted Viasat inquiring about his bill on September 7, 2020. A Viasat Business representative advised Mr. Metwally we had not received his transceiver.
On September 8, 2020, Mr. Metwally’s account was sent to collections due to its past due balance. As Mr. Metwally’s name was the one on the Customer Agreement, it was his contact information that was used in order to deliver the notice of collections.
As a resolution to Mr. Metwally’s complaint, Viasat has waived his unreturned transceiver fees as of March 22, 2022. Please note it can take the collection agency a minimum of 30 days to update their records, Viasat is unable to expedite this process.
Thank you for the opportunity to respond.
Viasat Satellite Service
Consumer Affairs Department
CC: Omar Metwally
From: Omar Metwally
Date: May 24th, 2022
Please keep this ticket open, as ViaSat has once again failed to keep its word. I received another collection letter in the mail today, attached.
Furthermore, please note that ViaSat’s response on 4/25/2022 states that “customers are responsible for returning Viasat’s modem and transceiver within 30 days after disconnection.” This statement is inconsistent with ViaSat employee John V’s email dated 07-30-2022, which refers to a “VoIP phone” and “routerboard” but has no mention of a transceiver. ViaSat provides contradictory and inconsistent instructions to customers, and they obviously don’t know what equipment they want returned.
ALL REQUESTED EQUIPMENT WAS ALREADY RETURNED ON TIME.
ViaSat are liars and criminals. Please hold them accountable for their predatory business practices and make them stop terrorizing innocent, hard-working people.
Omar Metwally, MD
Let it be known to all humans, past, present, and future, that ViaSat are liars, criminals, and terrorists.
By: Omar Metwally, M.D.
Objective: Design and 3D print a threaded cap that creates a water-tight seal with a threaded glass jar.
Environment: Autodesk Fusion 360
Glass jar dimensions:
Jar Outer Diameter (measured over threads): 48.06 mm
Thread Height: 11.88 mm
Metric Thread Pitch: 3.5 mm
Approach: Design a custom “coil” element.
Coil diameter (CD): Diameter of a zero-thickness coil as viewed from above (i.e. in the XY plane).
Jar Outer Diameter (JOD): Diameter of the jar opening, measured with Vernier calipers. Includes threads.
Coils: Protruding rings comprising the thread.
Section size (S): Coil thickness
Height (H): vertical height of the thread
Metric Pitch (P): distance between two adjacent coils
Revolutions (R): The vertical distance traveled by the coil (i.e. along the Z-axis of a cylinder) as it completes a 360 degree turn, beginning and ending at the same X and Y coordinates (i.e. looking down at the cylinder from above).
Tolerance (T): Arbitrary distance added to the coil diameter (CD) to allow the cap coils to interface with the glass jar threads.
1. Create a coil with coil diameter (CD) equal to the jar outer diameter (JOD).
CD = JOD
In this case,
Jar outer diameter (JOD) = coil diameter (CD) = 48.06 mm
S = 2 mm
H = 11.88 mm
T = 0.2 mm
Angle = 0.0 degrees
P = 3.5 mm
2. Calculate coil revolutions (R), remembering that one revolution is a 360 degree turn.
R = H / P
Revolutions = Height / Pitch
In this case,
R = 11.88 / 3.5 mm = 3.39 mm
3. Create the rest of the cap
The cap comprises the cap body combined with the coil. The body is a hollow (shelled) cylinder, and the coils can be either inside or outside the body. In this case, the coils are inside the body to create the shape of a female cap. The body inner diameter (BID) equals the coil diameter (CD) plus tolerance (T). That is,
BID = CD + T
In this case, we’ll use a tolerance (T) of 0.2 mm for a PLA print, and the body will be 2 mm thick, such that:
BID = 48.06 + 0.2 mm = 48.26 mm
BOD = BID + (2*2 mm) = 52.26 mm
By Omar Metwally, MD
August 4th 2021
This is a photo of Salt Lake City, Utah on April 3rd, 2020.
At the end of March 2020, I drove from the San Francisco Bay Area, my home of eight years, back to my home state of Michigan to volunteer in medical units overflowing with patients who were sick with the novel coronavirus. My puppy and my few personal belongings, which had consolidated over the years after frequent moves from one city apartment to the next, are packed into my Honda Civic, the rest of my belongings left behind in an apartment I quickly fled to avoid state border closures. Every fleck of my skin, from my face and lips to my toes, is swollen, red, and painful — a farewell gift from a patch of poison oak that my puppy discovered during one of our last hikes through the East Bay’s eucalyptus forests. I am on fire.
I drove from California to Michigan via interstate highways that traverse the heart of America with prescriptions for steroids to treat my case of fulminant poison oak hypersensitivity and an aloe plant on my lap. As I spent the better part of four days behind the wheel cutting off aloe leaves and rubbing them on my skin to relieve the intense burning that pushed me to the limits of patience, I reflected on how quickly life had changed in such a short period of time: the perpetual line of masked people in front of the deli where I used to walk a block over to pick up a sandwich for lunch and carry home fresh produce; the panic of trying to hunt down dog food after all the local pet stores shuttered their doors indefinitely; driving an hour and a half to Sonoma County in pursuit of milk; the tense, heavy atmosphere at my hospital as it filled up with seriously ill patients – and the limited therapeutic options doctors had at their disposal at the start of the pandemic.
Many people lost their lives and their livelihoods during the pandemic, which continues to take its toll around the world.
This is a photo of Salt Lake City, which I did not take because it wasn’t how I wanted to remember the capital of one of the most beautiful states in America.
After a few hours rest in a nearly-deserted hotel, I wake to continue our journey east. Except for a police patrol and a homeless man, there isn’t a soul on the streets of downtown Salt Lake City, as I walk my dog in search of a cup of coffee. This is not how a city should ever look, except in Cormac McCarthy’sThe Road. Even the national coffee chains one could previously count on were closed, and I resorted to brewing my daily cup of joe on the side of the road with the aid of a propane-powered camping stove.
Michigan was hit early and hard by the COVID-19 pandemic, but finding food for puppy and milk for me was still easier outside of California’s dense urban areas. When the State of California issued the first stay-at-home order in March 2020, it felt like standing on a beach watching tsunami waves roll toward land. While those tsunami waves are just now making landfall in certain countries that managed to dodge the first pandemic wave by means of fast, coordinated action, the aftershocks are being felt acutely by all. Personal loss and economic damage on such a large scale will take time to heal. The cost of basic provisions, from groceries to building materials, has increased markedly in just a few months, and the future is more uncertain now than it was in the pre-pandemic world.
Despite the great difficulty of finding a sewing machine and fabric in the spring of 2020, I managed to purchase my first sewing machine and learned to sew face masks with the help of a tutorial on the CDC’s website. The linen masks I created were far more comfortable and breathable than surgical masks, and I felt empowered to create something that had become as indispensable to daily life as a smart phone, especially at a time when masks were expensive and hard to come by. Just a few months before moving back to Michigan, I was taking my shorts to alterations shops to replace buttons, and I would have never imagined operating a sewing machine myself.
Learning how to sew gave me the knowledge and skills to harness an ancient technology – textiles – to create functional and beautiful things that can’t be made using 3D printers. After using the remaining linen to sew window drapes for our home, my next challenge was denim. A pair of jeans is both a tool and a lasting work of art. Subject to areas of extremely high tensile forces, jeans hold things together to keep us warm while serving as a physical barrier between our bodies and the world. Denim adapts to the shape of our bodies over time, and we hardly notice a comfortable, well-fitting pair of jeans as we go about our business. Jeans have front and back pockets to hold our keys, phones and wallets, and jeans take on a uniquely cool look with each wash, tear, fray and stain.
Levi Strauss of San Francisco and his business partner, Jacob Davis, a tailor from Reno, Nevada, were awarded U.S. Patent Number 139,121 (“Improvement in fastening pocket-openings”) for using rivets to reinforce pockets on May 20th, 1873 . There is a big difference between sewing trousers and sewing a durable garment that can withstand years of vigorous use. Strauss and Davis’ invention helped improve the longevity of jeans as a tool, a garment worn by people to help them work hard, and a garment that also happens to look nice!
As with face masks, I began sewing jeans out of necessity. Shopping for clothes to replace the wardrobe I left behind in California was impossible or extremely challenging for many months. Even before the pandemic, happening across a well-fitting pair of jeans involved visits to several outfitters and spending a day trying on jeans. If I was lucky enough to find a pair that fit, I didn’t have say in the properties of the denim I would bring home to break in: the fabric color, weight, style and stretch.
Jeans have become staples in apparel and are worn by people of every rank and file all over the world. The mass production methods necessary to achieve the current market prices rely on the sweat and lifeblood of factory workers who specialize in one small step in a complex process overseen by the proprietor. What surprised me most about learning how to sew jeans was the remarkable fine motor skills and intensity of labor which the process entails. With my wife’s help, we can together create a pair of jeans in three days: one day to take measurements, draft a pattern, cut fabric and serge the pieces; another day to sew the pieces; and a third day to add trimmings and hem. The price tags on store-bought jeans betray the immense skill and effort involved in creating a pair of shiny new blue jeans, but there is no price on the joy of achievement.
Whether I’m rounding in the hospital or under the hood of my car, I enjoy wearing a pair of hand-sewn jeans as a reminder that sewing jeans, like the practice of medicine, requires both knowledge and skill, a fruitful marriage of theory and practice. Creating a well-fitting pair of jeans requires a good grasp of human anatomy and the theory of pattern design. It requires an appreciation for how movement – walking, running, sitting and squatting – impart forces on the fabric, and how manufacturing techniques can reinforce these high-stress areas. Sewing jeans also requires appreciation for how denim is woven and dyed, and how its properties can be modulated to yield a certain feel and look. The theory of jeans-making must be combined with outstanding sewing skills to produce an awesome pair of jeans. Learning to work with a heavy fabric like denim takes a lot of practice and patience.
Even if I had an endlessly long list of customers, a mom-and-pop jeans shop operating in the United States cannot compete head-to-head with a jeans factory that outsources its operations to places where the cost of labor is significantly lower. And while I can’t pretend to be an expert seamster as far as sewing jeans is concerned, practice makes perfect.
A pattern can be purchased separately from the jeans so that people with sewing skills can create their own jeans at home.
To purchase a custom jeans pattern and/or a pair of custom-tailored jeans, request an order form by emailing me (email@example.com) with “Ox Jeans Order Form” in the subject line.
The strain of the COVID-19 pandemic on society and healthcare systems turned fine fault lines into gaping canyons. Reflecting on my writings about U.S. hospitals 5 years ago, I asked myself what had changed and what still must change to rebuild a healthcare system that can deliver medical care wherever and whenever it’s needed. What problems were prevalent in the healthcare system before the pandemic, and how did the pandemic highlight these deficiencies? In my day-to-day work as a doctor, what diverts my time and energy away from the most important and fulfilling aspect of doctoring – patient care?
Direct and effective communication with patients is the most important aspect of healthcare, in my view. A doctor working in the community who is licensed and certified has demonstrated a body of knowledge and skills to provide medical care within a certain scope of practice. Someone with a health concern is arguably not seeking the smartest doctor they can find; they want a doctor with whom they can communicate their concerns, understand their health issue, and make a mutually acceptable treatment plan. In daily practice, I feel that 95% of my time and energy are consumed by tasks that do not relate directly to patient care. Even more unfortunate is the fact that these 95% of tasks are the ones by which doctors are evaluated and compensated: clicking through electronic health records (EHR), wrestling with flawed communication systems (such as hospital phones, pagers, texting, and email) to receive and share information with other members of the healthcare team, answering “queries” from hospital administration for the purpose of billing patients and insurance companies, and wasting life-years trying to wrangle health information systems as mandated by hospital administrators and insurance companies.
1. The world wide web
The pandemic pushed the role of “telemedicine” (healthcare rendered by phone or digitally) into the foreground as a way to deliver healthcare efficiently while reducing the spread of the coronavirus. Regrettably the first and biggest problem with healthcare is internet connectivity and how EHR software sends and receives information between a doctor’s phone/computer and the hospital server. Even in the year 2020, reliable, high-speed internet is a scarce resource in the United States. Most Americans have no choice of internet service provider, if they are lucky to even have access to one. In a time where human resources are stretched thin and inefficiently used, trying to reach a human in the event of a service interruption can easily waste hours if not days waiting on hold or confined to chatbot purgatory. Many doctors now work remotely to a large extent, if not entirely. Reliable, fast internet is prerequisite to being able to deliver good healthcare. This is especially true because of the nature of EHRs, which use “Virtual Machines” and “Remote Desktops” that require a reliable, low-latency, high-speed internet connection. A client that runs at a snail’s speed and frequently disconnects, requiring 10 minutes to repeat the authentication process before dropping the connection again, is severely detrimental to patient care.
2. Electronic Health Records
EHRs are essentially spreadsheets in fancy packaging. They’re not smart in the sense that a phone is smart; they don’t learn, predict, or automate tasks. In fact software that is slow, requires a lot of clicking and non-intuitive behavior, and which wastes a lot of time with authentication and logging in, is not much better than typing text into the simplest text editor and saving it in a rudimentary database. That is the core of a hospital or clinic’s information system: text and media files saved chronologically and accessible to the right people at the right time. I prefer to type or dictate notes freestyle rather than use templates because it’s faster for me, gives me more control over the document, and helps me communicate my assessment and treatment plan more effectively than relying on a template created by someonen else who may conceptualize a diagnostic process and treatment plan much differently than their peers. An ideal EHR to me would simply be typed into a Unix terminal (for a reader unfamiliar with Unix, imagine a black screen with a flashing white cursor) and piped into a hospital server, which would then use the text to help doctors appreciate the clinical Gestalt or “big picture”: what could harm or kill the patient in the next few hours? And beyond the first 12-24 hours, how to safely discharge the patient? As an EHR user, I don’t want a fancy front-end trickling through a lagging virtual machine; I want a simple, low-latency, text-focused interface and a smart backend, in other words, very simple software that looks dumb but is actually smart.
On top of the pressure of having to synthesize a huge amount of dynamic information to make fast and sound decisions about patient care, doctors are inundated and constantly interrupted by communications from other members of the care team. Doctors work closely with nurses, aids, phlebotomists, lab and radiology technicians, doctors from different specialties, clerks, social workers, insurance companies, and hospital administrators. There is a lot of information constantly moving back and forth in real-time between all parties. This flow of information is often like a waterfall rather than a water faucet – the communications are not prioritized and frequently fail to reach the right person at the right time. There are times when a doctor’s attention should be focused entirely on the task at hand, for example when assessing or speaking with a patient at bedside. This is no time to be interrupted with billing queries or non-urgent questions about other patients’ care. A constant stream of unprioritized and unfocused information can make it extremely difficult to focus on the critical 1% of information which can hurt patients if this information is not processed correctly at the right time. In order to hold people accountable for their decisions, they need to be given a fair chance, with tools that work without draining life out of the users. A page or phone call that may or may not find the intended recipient, and a note left in the EHR saying, “tried to call you but you didn’t answer your phone,” is subjective and not constructive without a way for all parties to track communications from their origin to their destination.
In addition to the right tools, there is a need for sound systems. A doctor’s extensive education and training culminates in a highly specialized set of skills and knowledge. Doctors should take pride and joy in their work; they endured long, grueling training out of a desire to help humanity. Out of training, doctors traditionally became their own bosses, working in community hospitals or private clinics, practicing medicine the way they were taught in a style that becomes their own. Nowadays doctors are managed by administrators who are not doctors. There is a reason why healthcare systems look and function the way they do, an evolutionary end-product of decades of legislative, financial, operational, and societal forces exerting themselves on doctors and hospitals. Back in the day, doctors saw their own patients in their own clinic and treated their patients when they were hospitalized too. This is exceptional nowadays. There was no, “I’m your doctor for today,” or “I’m your doctor this shift, until 8pm.” The reality is that this mode of doctoring has become rare. Having experienced the modern-day flavor of corporate medicine in urban areas and the more traditional model in rural areas, I appreciate the pros and cons of both models. “I’m your doctor, period” can be spoken by a doctor lucky enough to escape corporate medicine, but also a doctor prepared to withstand the stress of not having any personal or protected time away from work. Too many talented doctors nowadays burn out after short-lived clinical careers, depriving patients of the care of great doctors who fell victim to the 95% non-clinical burden on top of the already stressful 5% clinical work.
4. More communication
There is a clear line between “outpatient” and “inpatient” medicine in most doctors’ minds, that is, healthcare delivered in a clinic, where a patient goes to an appointment and returns home, compared to a hospital, where a patient stays overnight. Patients don’t think in terms of “inpatient” and “outpatient.” A patient who wakes in the middle of the night with a fever and shortness of breath, or a patient with a growing breast lump, have concerns that needs to be addressed immediately by someone who actually cares. It sounds obvious, but I could not copy and paste this phrase too many times: by someone who actually cares. Not a voice menu, not a chatbot, not “Due to unusually high call volumes…,” and not a tired, under-paid clerk who is poorly equipped to do their job. A doctor has the knowledge to assess whether a problem is urgent or not urgent, concerning or likely harmless. It’s not fair or realistic to expect patients, lacking specialized knowledge, exposed to the vast informational waste littering cyberspace, biased by personal experience and anxiety about a health condition, to make those calls.
“Due to unusually high call volumes…” has become this year’s mantra. Nearly every call I attempt to place to an insurance company, hospital, or clinic is met with this phrase and indefinite wait times, now nine months since the start of the pandemic. Most negative feedback about doctors and hospitals relates to what goes on beyond the few minutes a doctor spends interacting directly with the patient: a medical assistant having a bad day, a disorganized clinic, the insurance labyrinth, bills…human concerns not being reciprocated by a human in a place to care and do something about it. Most of the time and energy spent by patients trying to get help for a health concern is burned in the friction of waiting on hold and clicking through websites to try and make appointments or navigate insurance and billing departments. Putting this burden on healthy people is absurd. This is a lot of life wasted by a lot of people. There needs to be a much less painful way to pick up the phone and route a health concern to someone with the expertise to address the concern. Putting this burden on someone who is sick and possibly dying is criminal.
5. Paying for healthcare
Healthcare is too expensive to fund primarily through private insurance. This is the clearest take-home point of the pandemic to me as a doctor and as a patient. I recently “downgraded” my health insurance because it is by far my biggest monthly expense after my mortgage. For the past year, I purchased expensive health insurance and hardly used it. Miss a payment, and insurance companies will not hesitate to end coverage as soon as the clock strikes twelve, as swiftly and thoughtlessly as a robot. I am fortunate enough to have a job. Many people do not and were already barely just getting by before the pandemic. We no longer have the luxury of deciding whether or not a single payer system is good for America. We are well past that point. Healthcare, especially now, can only be funded by a payer pool on a national level. In my view, healthcare is a human right. This is not a political issue to me. This is a human issue. Everyone should have access to at least a basic level of healthcare: when you have a health concern, you should be able to see a healthcare professional as quickly enough as the issue warrants, without breaking the bank, without bankrupting society.
I had the opportunity to work in German hospitals during my medical school international rotations. There is no such thing as uninsured in Germany, and many other countries with nationalized healthcare. Everyone can get urgent and non-urgent healthcare without going bankrupt. In my view, universal healthcare (and access to universally affordable education) is the foundation of a sound, healthy society. How much money one has in the bank should not delay access to healthcare. Those with the means to purchase private health insurance are free to do so, along with the benefits this might entail. The reality is that healthcare is expensive. Diagnostics and therapeutics – CT scans, MRIs, lab tests, prescription drugs – cost money to develop and deliver. We are all humans, and illness is inseparable from the human experience. Everyone will have contact with the healthcare system at some point in their life, and most Americans are born and die in hospitals. The sooner we accept this reality and have empathy for the suffering of others, the sooner we can make better decisions for how our healthcare system will look and function in the recovery period following the pandemic.
Omar Metwally, MD // 16 December 2020
We’re walking through Hanoi’s Old Quarter on a warm spring day, dodging motorbikes on crowded streets, passing cafes and crowded curbside restaurants. The smells, sights and sounds of an endlessly lively Vietnam are constant companions. For miles in all directions, mom & pop t-shirt shops line the streets selling variations on common designs, many inspired by political satire. The shirts range from 60,000 VND (~3 USD) to about 10 USD, the final sale price depending on one’s skill in haggling, ability to establish rapport with the seller, and the extent of one’s Vietnamese. What’s original today will quickly be copied and re-copied until it becomes a jaded afterthought in the public domain.
A dragon lurks in the corner of my eye: black dragon on grey background, a striking image. The shop owner says he’s the only one selling it Hanoi, and after acquiring a new wardrobe during the course of my travels from Saigon to Hanoi, I have no reason to doubt him. Only – it’s a size too small, and I want two custom shirts made with black and red dragons on white background. He assures me he’ll have the shirts printed in just a few minutes, and indeed, 10 minutes later he sells them at a steep profit for $5 each, in time to greet the next group of visitors admiring the shirts hanging in the entrance.
Two weeks in the Land of Smiles was a remarkable lesson in good humor, fine coffee, delicious cuisine, and business savvy. Haggling with Vietnamese merchants was endless fun, in large part because of the opportunities to get to know the beautiful families who greeted us with kindness and generosity.
One eye-opening take-home business lesson as it relates to my team’s work on a 3D-printed e-bike has been the value of 3D printing in quickly putting highly customized products in customers’ hands, the manufacturing industry’s equivalent of a custom-printed t-shirt or a handmade leather wallet. In a time of intense competition in global marketplaces, there is value in custom-made products, and there are those who appreciate their significance – in Vietnam, and in America.
Omar Metwally, MD Analog Labs 19 November 2018
It was a bright cold day in April, and the clocks were striking thirteen. Winston Smith, his chin nuzzled into his breast in an effort to escape the vile wind, slipped quickly through the glass doors of Victory Mansions, though not quickly enough to prevent a swirl of gritty dust from entering along with him.
Opening paragraph of George Orwell's Nineteen Eighty-Four. 306 characters, including spaces.
I did some back-of-the-napkin math to calculate how much it would cost today to upload George Orwell’s novel Ninteen Eighty-Four to the Ethereum blockchain.
To upload the opening paragraph using this Ethereum contract (there are much more efficient ways to accomplish this using Solidity), the transaction would cost 290697 gas under current network conditions. If the entire 576,789-character novel were uploaded in the same manner, it would cost 576789 * 290697 / 306 = 54743895.20588 gas. Gas is currently about 2.2 * 10^9 wei .
(54743895.20588 gas) * (2.2 * 10^9 wei / 1 gas) * (1 Ether / 10^18 wei) = 1.2 Ether.
The carat symbol (X^Y) here indicates “X to the power of Y”.
In this manner, Orwell’s Ninteen Eighty-Four would cost 1.2 Ether to upload to the Ethereum blockchain, where it would be permanently and publicly available, served by more than 10,000 nodes.
If Ether were regarded in terms of its utility rather than as a speculative or financial instrument, there would likely be much less price lability, assuming society’s utility for a technology in general changes at a much slower rate than a market’s enthusiasm for securities and commodities. For instance, the cost of electricity in the residential setting varied from an average of 11.26 cents per kWh in 2008 to 12.89 cents per kWh from 2007 to 2017 . Contrast this with the cost of Ether ranging from less than $1 in 2015 to more than $1,400 in early 2018.
How much does Ether really cost? A dollar? $100? $1000?
One way to begin answering this question is to study current market rates of cloud hosting services [3, 4]. Google offers a 2TB standard storage tier at $0.000274 per hour, and Amazon’s standard EC2 instances can range from $94 to $2,367 annually. A direct comparison with the cost of uploading Orwell’s novel is inaccurate because:
I offer file storage as an imperfect thought experiment because a significant part of what consumers pay for when purchasing a smart phone is the ability to store large amounts of media, access and share these data. This thought experiment is only a starting point to answering the question of how much one Ether actually costs.
It took decades for the internet’s value to manifest, which today often takes the form of profiling users and using this information to sell digital ads. As one of my academically-minded siblings keenly points out, however, one important difference between the origins of the internet as we know it today and blockchain networks whose tokens are traded on exchanges is that the internet was built in a more farsighted manner without the objective of making money for speculators. ARAPANET, the precursor to the modern internet, initially ran on four Interface Message Processors (IMPs) at UC Santa Barbara, Stanford, the University of Utah, and UC Los Angles . Of course, the internet has changed dramatically since its early years, and technology in general is constantly evolving under the pressures of regulation and free markets.
Crypto markets poisoned blockchain research by muddling networking protocols and stake in open source projects with financial speculation. On one hand, capital is an important element of many large endeavors. On the other hand, skyrocketing prices and price lability can breed greed, resentment, and hinder the ability of programmers, consumers, and researchers to actually use networking protocols. The lower the price of crypto, the cheaper the transactions on the network and the more accessible the protocol is to the average consumer.
So how much does Ether really cost? A dollar? $100? $1000?
One step toward answering this complicated question is to ask: how much would you pay to perpetually host George Orwell’s Nineteen Eighty-Four (or another 590kb text file or image)?
Omar Metwally, MD Analog Labs 15 September 2018
She was one of the truly fortunate people who discover what they love to do, have the means and the courage to follow their passion, and the gift to share their discoveries.
Robin Hanbury-Tenison on botanical artist Marianne North
Traveling in Japan with friends, Robin Hanbury-Tenison’s The Great Explorers captivated and inspired me with a collection of biographies of courageous individuals who explored and discovered continents, oceans, deserts, caves, and rivers. These people lived in times when large parts of Earth’s surface were unknown to humanity and entirely uncharted, and their stories left me wondering which frontiers stand before their contemporaries in pursuit of advancing society’s collective knowledge.
Most of these explorers lived before the advent of the digital age, relying on analog instruments to study terra nova: magnetic compasses, sextants, pacing beads, and their powers of observation. A journey that spans thousands of miles over years requires a deliberate estimation of the minimum amount of equipment necessary to facilitate their survival and studies without burdening them. In stark contract, we live in a time of abundant and oftentimes superfluous technology. During the past weeks of travel, I meditated on the question of how much technology one actually needs without becoming burdened by it. Every day reminded me of the joys of good company, the mind’s capacity to acquire languages, the utility of answering questions by asking locals rather than searching the web, and a postcard’s ability to distill thoughts into a memorable moment. Translation software and internet access, while sometimes handy, are no substitute for a sound grasp of a foreign language and asking locals how to get around. Google can help translate a phrase in a pinch, but it’s unlikely to know that a typhoon blocked a bus route and that a taxi driver will find the safest way home.
Richard Burton taught himself to speak 27 languages by the time he died in 1890, and his mastery of cultural camouflage opened doors to civilizations in Africa, India, and the Middle East which would have otherwise been closed off to Europeans of his time. Gertrude Bell, the first female officer in British Intelligence, mastered Arabic and Persian, translating poems by Hafiz as she trekked across deserts meeting local sheikhs and tribe leaders.
The tools one has at hand bias one’s approach to discovery. Compare our trip to Japan, for example, with that of Francis Garnier, who embarked on a treacherous journey to explore the Mekong with his crew. Compared to Garnier’s crew, we enjoyed every luxury available to modern travelers: airplanes, hotel reservations at our fingertips, smart phones, and Google Translate. And should we stray from cell reception or forget to charge our phones, my GPS-connected RPI can still pinpoint our whereabouts anywhere on Earth. Unlike the fearless explorers who risked life and limb in pursuit of beliefs, passions, or sheer love for discovery, who immersed themselves in native cultures and dedicated lifetimes to observing and describing, one might say we left Japan only slightly more acquainted with its people and culture as when we arrived.
Humankind – the individual mind and collective human behavior – is a perpetual frontier. Know thyself, so the wisdom of ancient civilizations. Most interesting to me and pertinent to my research is the question of how human societies can use finite resources to provide better lives for future generations. A solitary zero-sum endeavor has the potential to become a vast leap forward when knowledge is shared effectively with a global village. This is what excites me most about open source collaboration and paradigms of participatory computing, such as peer-to-peer networking and data structures based on them.
Norwegian explorer Roald Amudsen left his medical studies to pursue his childhood dream of traversing the Northwest Passage. Having gone into debt to acquire a shipping vessel and assemble a team that would succeed in achieving his childhood dream – as well as becoming first to reach the South Pole – he departed on his journey hours before debt collectors planned to seize his ship. Debt was a recurring theme in many of these ventures, and many explorers burned through personal fortunes, imperial funds, or private capital to fund their expeditions. Amudsen’s story is an example of humankind’s capacity to lift itself from its own bootstraps, to produce lasting humanistic and technical works that are greater than the sum of individual labors. Amudsen’s successful return converted the same debt collectors into patrons and benefactors eager and proud to support his future voyages.
I chronicled our trip on the Ethereum network for the sake of posterity and to illustrate the utility of technologies that have grown into areas of interest and focus for me. For non-technical users, the easiest way to download these points from the Ethereum blockchain is to use the Ethereum Mist Browser (similar to a web browser for blockchain). They can also be downloaded using numerous command-line frameworks for interfacing with the blockchain, such Web3py.
Fleet Fox contract address:
Many colleagues and friends have asked me, in the context of the distractions of financial speculation, why anyone would bother developing an application on a blockchain and forego the relative ease and inexpensiveness of services offered by large, established corporations. The reason why most people, myself included, use services offered by large tech companies is because they sell useful products. It is the logic of a free market. For example, I have a MacBook and iPhone, and I have benefitted from Apple, Google, and Amazon’s products. My work studio is also filled with home-made computers running Linux-based operating systems, and I use the Ethereum blockchain on a daily basis to run my and others’ code, which performs familiar tasks such as networking, storing, and moving information. To enjoy the convenience of mainstream products such as iMessage, iCloud, and iPhone, one must pay the Apple “tax” by purchasing one’s way into the Apple ecosystem, an exclusive gateway to access one’s multimedia, emails, text messages, documents, and personal contacts’ information. To enjoy the convenience of Google’s cloud, one pays the Google “tax” by waiving a certain degree of privacy and control over one’s personal data, which is only as permanent as a recurring credit card payment, the company’s existence, and the output of its machine learning algorithms. The same analogies and parameters can be extended to Facebook and Amazon.
The notion of transaction costs on blockchain networks is the analogous “tax” one pays for the security, persistence, and control over one’s information on a decentralized network, which are sacrificed more or less when relying on corporations. It is the cost of digital sovereignty. At the time of writing, the transaction cost of uploading each individual GPS location onto the blockchain cost 0.0004164664 Ether, or $0.09 at a rate of 1 ETH = $220 USD.
Blockchain technologies are in their infancy. Using a Blockchain Messaging Service today reminds me of sending email in the early 90s, when my uncle (a networking engineer) and a few hobbyists in the UK and Japan, whom I had never met, were the only people in my address book. One of my first books was a kid’s guide to the internet, which listed a handful of websites, such as Nickelodeon, Kellogg’s, and NASA, along with the authors’ advice to have a pencil and paper handy to doodle because some images (very low-resolution by today’s standards) could take up to 30 minutes to load on slow dial-up connections. Like those early days of the internet, blockchain applications still have a long way to go. And that’s what makes working with this technology fun and worthwhile. It’s a new frontier.
Fleet Fox (Github repo | Fleet Fox receiver) is an application that allows decentralized exchange of information and value tied to one’s physical location. It’s built on the same open source infrastructure I’ve used to chronicle our trip to Japan, and I’m excited to pilot the technology as a backend for vehicle fleet-sharing services in coming months. I would be grateful for and humbled to receive feedback from fellow explorers using it to collaboratively build a behavior-centric map of the world on the Ethereum blockchain.
One of my family friends congratulated me recently on the success of the ‘Ether startup,’ leaving me briefly puzzled. While the parallels between issuing common stock, stock options, and digital tokens are relatively intuitive, this was the first time I heard an open source community described as a company — by someone unfamiliar with open source software. Technically, Ethereum isn’t a startup but an organization rooted in open source communities working to develop decentralized, logic-gated information and value exchange. There are similarities, and differences, between open source communities funded by digital tokens and traditional startup equity.
Transitioning from a Clinical Informatics fellow at UCSF to starting an R&D lab has provided me an opportunity to reflect on the valuable mentorship I’ve been lucky to receive along the way.
Analog Labs is an applied research laboratory aiming to:
The excitement surrounding cryptocurrencies drew attention to a field in tech that had been niche until relatively recently. Capital allows companies to grow and subsequently create value for society. However too rapid influx of wealth into cryptocurrencies can outrun the ability of these technologies to mature and evolve. Rapidly increasing prices of cryptocurrencies can bring wealth (and ruin) to speculators and can also discourage the spending of Ether to actually run applications. The excitement surrounding the industry, despite being a source of attention and potential investment funds, needs to keep pace with the development of these technologies for the sake of the long-term health of these technologies.
Since I started purchasing health insurance last month — $902.04 per month for medical insurance and $32.52 per month for dental insurance — I’m reminded of the dizzying cost of healthcare in the United States — the glaring economic and public health problem that sparked my interest in Ethereum several years ago. Analog Labs’ flagship project is a study of grassroots primary care models on the Ethereum blockchain. This living experiment is an opportunity to tap into a body of literature in Global Health and international communities’ experience with designing creative solutions to the challenge of funding healthcare’s perpetual journey to better.
Analog Labs is also seeking to help develop 2-4 projects that further the lab’s goals of applied research for sustainable social good by providing funding, technical expertise, and collaborative work, especially in the areas of:
I’m grateful to Betty Tran, Steven Truong, Peter Mikhail, Royd Carlson, The Haham-Grossman family, Linh Tran, Darlene Nguyen, Dr. Blake Gregory, Dr. Indhu Subramanian, Dr. Taft Bhuket, Dr. David Avrin, Dr. Sidhartha Sinha, Dr. Scott Enderby, the Highland family, the UCSF community, Bella Shah, Seth Blumberg, Dana Gersten, Tanner Irwin, Youssif Abdulhamid, Shahzad Ahsan, and friends at UCSF’s Aldea community for their support, mentorship, and contributions to this work.
Omar Metwally, MD