I wish this were satire. It is not. The numbers are real, and so is everything else.
Written by Omar Nabil Metwally, MD, physician-dissident: a licensed, Internal Medicine board-certified physician with a perfectly clean malpractice record, professionally orphaned in a country without a functional healthcare system.
I. The Cover Letter
Dear United States,
Enclosed please find a final invoice. I am closing my account.
I have been meaning to write since May 2018, when I first bought health insurance from you directly, through a website, the way one buys a toaster.
I am a physician. Until recently I earned about $145,000 a year, paid my taxes early, carried no debt, and took a certain pride in all three. Then the healthcare system I had been paying into for most of my adult life messed up my right leg. I will spare you the clinical details. The short version is that I cannot afford the surgery that would fix me, and the hospital sends me bills. This month it sent one for my daughter. Forty dollars. That was the one that did it. Not the leg. The forty dollars.
I want to be clear that this is not a complaint. I am past complaining. The people are fine. Most of them are tired. The arrangement, under which I pay you, and then I pay Blue Care Network, and then, when I am sick, I pay again, is not something I am asking you to fix. Yesterday I received good news and bad news. The good news: Blue Care Network of Michigan approved a prior authorization for a hip MR arthrogram (a study that involves injecting contrast into the hip joint just before getting an MRI). Orthopedic surgeons use the results of these imaging tests to help them plan surgery. The bad news: with an $18,000 deductible, despite prior authorization, I still have to pay the cost of the study (several thousand dollars) out of pocket, in addition to my insurance premiums.
I have had some time off my feet to think about it, and I have done what one does with any subscription that has stopped working. I have cancelled it. I have already left. This is the closing statement.
I do not blame my countrymen. They do not know any better. They have been told their whole lives that the more you pay, the more you get, and since they pay more for healthcare than anyone on earth, it follows that they must be getting the most. They are not. Among the countries rich enough to run the comparison, theirs pays about twice the going rate and dies the soonest. I say this with no disrespect to anyone else’s hospitals. I say it as someone who has stood on both sides of the bed, back when I could stand without cursing in pain. The arrangement is not a healthcare system. It is a subscription to the belief that you are in one.
The invoice covers two things. First, the premiums my family paid out of pocket for Marketplace coverage, net of the credits you already applied. I have deducted those because I am not a monster. Second, the share of my federal income tax that, by your own accounting, went to health programs in the same years. I am not asking for all of my taxes back. You can keep the roads. I will not be using them. I am asking for the part that was supposed to buy a functioning healthcare system and did not. I have also added the Global Entry fee. I understand it is nonrefundable. So was the leg.
Interest is charged at your rate, not mine: seven percent, compounded daily, which is what you charge me when I am late. I assumed you would want to be treated the way you treat others.
Terms are net 30. I have no evidence that you will pay. I have no evidence that you will read this. A bill that is never sent is not a bill; it is a feeling, and I have enough of those. So I am sending it. One settles accounts before leaving. It is the only part of the arrangement I still believe in.
Yours, from the exit,
Omar Nabil Metwally, MD, physician-dissident
II. The Invoice
FINAL INVOICE. Account closed at the customer’s request.
Invoice no.
1095-R. The R is for refund.
From
Omar Nabil Metwally, MD, Ypsilanti, Michigan. You have the address. You write to it every January.
To
The United States of America, c/o Department of the Treasury, 1500 Pennsylvania Avenue NW, Washington, DC 20220
Copy
Health Insurance Marketplace, 465 Industrial Boulevard, London, Kentucky 40750-0001, the return address on every form cited below
Date
October 21, 2026
Terms
Net 30. Due November 20, 2026.
Diagnosis codes, ICD-10-CM. These are real. You can bill for them. I am.
Z59.7 — Insufficient social insurance and welfare support
Z59.86 — Financial insecurity
Z75.3 — Unavailability and inaccessibility of health-care facilities
Y69 — Unspecified misadventure during surgical and medical care
Proposed for the next revision. Submitted to CMS by the usual route, which is to say, posted here.
Z00.USA — Receipt of the most expensive healthcare on earth; value received, unspecified. Patient believes that paying more means getting more. Patient has not been told otherwise.
Statement
Tax year
Months covered
Premiums I paid, net of your credits
Health share of my federal income tax, 31.2%
Interest, 7% compounded daily from Dec 31
Line total
2018
May–Dec
$1,708.72
$4,495.92
$4,514.30
$10,718.94
2021
Jan–Mar
$941.16
$5,854.99
$2,719.13
$9,515.28
2022
Jan–Sep
$1,173.78
$3,221.71
$1,342.61
$5,738.10
2023
Jan–Dec
$1,519.32
$5,521.15
$1,529.22
$8,569.69
2024
Jan–Dec
$6,728.16
$6,908.30
$1,836.88
$15,473.34
2025
Jan–Dec
$7,879.20
$9,273.89
$994.84
$18,147.93
Subtotal
$19,950.34
$35,275.96
$12,936.98
$68,163.28
Other items
Item
Amount
Global Entry fee, nonrefundable
$120.00
Right leg, one, previously functional
Not billed here. That invoice goes to someone else.
TOTAL DUE: $68,283.28
Notes
Premiums are Column A less Column C of each year’s Form 1095-A: $39,312.34 billed by the plans, of which you paid $19,362.00 in advance credits. Thank you. The years not listed were employer coverage, taken out of my paycheck before I saw it, which is a different invoice.
Federal income tax is the total-tax line of each year’s Form 1040, $113,064 across the six years. The 31.2 percent is the share of federal spending that went to health programs in 2025, by the Tax Foundation’s reading of OMB’s historical tables. I have applied the 2025 share to every year. It was lower before the pandemic. You may dispute it. I would welcome the correspondence.
Interest is 7 percent, compounded daily: the rate you set for individuals for the quarter beginning October 1, 2026 (IR-2026-98). It runs from December 31 of each year, not from the month each premium was paid, so it undercounts. You’re welcome.
III. Terms
Payment is due in 30 days. After that, the balance accrues the penalty you charge me when I am late: one half of one percent per month, to a maximum of 25 percent, with interest on the penalty. I did not invent these numbers. I copied them from your website.
Payment may be made by check, wire, or yacht. I used to pride myself on having no debt. I am now running an experiment to see how much medical debt a human can carry.
Remit to the address on file. I will not be sending the Washtenaw County Sheriff to collect the house and my two cars (including my wife’s car, which is under my name). I understand that is your move, and I would not want to deprive you of it.
Disputes may be submitted in writing. I will read them from abroad, somewhere with hospitals, where the premiums are called taxes and the taxes buy a hospital. I will not be taking calls. I have spent enough of my life on hold.
This account will not be renewed. Please stop writing to me in January.
IV. A Note on Delivery
This invoice is not being filed with the Internal Revenue Service. I looked into it. A return or refund claim the Service finds frivolous carries a penalty of $5,000 under section 6702, which reaches any submission that “reflects a desire to delay or impede the administration of Federal tax laws.” I have no such desire. I have a desire to be paid. But I am a physician, not a lawyer, and I have learned what it costs to find out what a sentence means. So the one safe way to send my government a bill is not to send it, and to post it here instead, where it will be read by the only people who were ever going to read it.
To them I will say one thing, and then I will go. You are not getting what you pay for. You never were. Here, the more you pay, the more you have paid.
Thank you for the opportunity.
FIN
Sources
Forms 1095-A for tax years 2018 and 2021 through 2025, and the total-tax line of the Forms 1040 for the same years. Mine.
Peterson-KFF Health System Tracker, How does U.S. life expectancy compare to other countries?, March 31, 2026: 79.0 years in the United States in 2024, against 82.7 in comparable countries, the lowest among peer countries for both women and men.
ICD-10-CM: Z59.7, Z59.86, Z75.3 and Y69 are real, billable codes, titles as AAPC lists them. Z00.USA is not. Yet.
By Omar Nabil Metwally, MD Friday, October 9, 2026
The operating room is as I remember it. The retirement is imagined.
I. The Gift
One of the most valuable things I took from medical school was feedback. An immense amount of it. Feedback on my presentations, my notes, my knots, my differential, my tone, the way I held a retractor, and the way I held it after being told how to hold it.
More valuable still was the humble art of receiving it. You nod. You say thank you. You go home and get better. Medicine runs on this arrangement: you are corrected for about a decade, and you learn to treat every correction as a gift, including the ones that arrive unwrapped.
What nobody mentions is how rarely the current reverses. As a student, almost never. Later, as a resident or as faculty, every once in a while someone hands you a form and asks what you think.
II. The Form
I was remembering one of those forms: my exit interview from the University of Michigan Medical School. The school wanted to use it as an opportunity to improve, as it is always trying to do.
An aside before I go on. I can write this story because I think Michigan Medicine truly does set the bar for quality of healthcare in Southeast Michigan. This is by no means a rant. It is a personal reflection, thinly wrapped as an offer of constructive feedback. It was the only wrapping paper I had.
The form had a section on bullying and harassment. It gave me about three lines.
III. The Towel
During my surgery rotation, I dropped a towel on the operating room floor. It left my hands and went to the ground, the way towels do.
The scrub tech noticed. He was a heavyset older white man, and he had clearly been noticing towels for a very long time. He pushed me and said:
“Did you just drop a towel?”
“Yes, sir?”
I said it with the intonation of a question, because I was anticipating his next sentence. I expected to be handed the opportunity to say: I apologize, sir. Let me pick it up and scrub back in. That was how feedback had always worked. Observation, correction, gratitude.
Instead he told me:
“If you drop one more towel, I’m going to rip your balls off in front of all these women and throw them in the trash.”
IV. The Assessment
I have had fifteen years to review this feedback, and I want to be fair to it.
It was timely, delivered within seconds of the event. It was specific. It was actionable: one more towel. It named an indication, a procedure, an audience, and a disposal plan. To this day it is among the most complete operative plans anyone has ever presented to me in an operating room.
My only notes are technical. The trash is the wrong receptacle; that is what the red bags are for. No consent was documented. There was no time-out.
I wrote none of this on the form. I had three lines. I narrated a brief summary of the incident and moved on to the next question.
V. Fifteen Years Later
Thirteen years later. Actually, more like fifteen. I am an attending physician now, and it is interesting to hold this story up to the present light.
We live in a day and age of hypersensitivity. Anaphylactic sensitivity, even, where political correctness is concerned. To be fair to the immune system, anaphylaxis is a reaction to something: in this case, an extremely polarized, energized, fired-up world. The response is outsized. The allergen is real.
I am not sure what would happen if such an incident took place today. I would rather not even think about it. I suspect it would take more than three lines.
VI. Urologists Without Borders
Instead, I think about him.
I imagine him fifteen years on, comfortably retired, well pensioned by the university or by the union or, knowing him, by both. I imagine that retirement did not suit a man of his energies, so he volunteered. The organization is called Urologists Without Borders. It travels to war zones. He is its volunteer urology tech.
Afghanistan. Ukraine. A tent, a generator, a tray of instruments laid out with frightening exactness. I imagine the young surgeons adore him. I imagine that nobody in that tent has ever dropped a towel, and that nobody can quite remember why.
I imagine he has spent his retirement patiently helping to put back what he once proposed to remove. He is very good at it. Nothing goes in the trash that does not belong there.
And I imagine a local medical student, hands shaking, letting a towel slip. He looks at the towel. He looks at the student. He bends down, at his age, with those knees, and picks it up himself.
“Happens,” he says.
That is the whole fantasy. It is not revenge. I checked.
VII. The Closet
One more thing. The incident gave me a lot of food for thought. It really stoked my curiosity about a career in surgery, and in medicine in general.
I used it as an opportunity to learn, and to think carefully about whether I wanted to start my residency immediately or, alternatively, move into my close friend’s closet in his San Francisco studio apartment.
I chose the closet. I lived in it for a year, and we started our first company there. Then I did, eventually, go to residency.
Bottom line: looking back, no regrets. I would go back to San Francisco in a heartbeat. Nobody in that closet ever pushed me, and I could drop whatever I wanted.
VIII. On Professionalism
So this is a reflection on giving feedback, which turns out to be harder than receiving it. Receiving takes humility. Giving takes something more: you have to believe that the person on the other end is capable of being better than their worst sentence.
I believe that about him. I would like to think someone believed it about me, on the day I dropped the towel.
Professionalism is not the absence of dropped towels. Towels get dropped. It is what we say next, and that is the humane and human part, the part that brings us together as people and as professionals.
So, sir, if you are reading this from a tent somewhere: thank you for the feedback. I have implemented it. I have been very careful with towels ever since.
Yes, sir?
Addendum
This essay has since been submitted to JAMA, to NEJM, and to all the big ones. In the version of events I prefer, every one of them published it.
So picture a Sunday in San Francisco. A group of retired surgeons is having brunch. The journal is on the table, the physical one, on actual paper, passed from hand to hand between the eggs and the sourdough.
They read in silence, the way surgeons read, which is quickly and with visible disapproval.
Then one of them puts the magazine down and says, in a high-pitched Mickey Mouse voice:
“I know exactly which scrub tech he’s talkin’ about.”
A chorus of Mickey Mouse laughs goes around the table. Nobody drops anything.
The recollection is mine. The retirement and the brunch are imagined, as is the publication, and any resemblance of Urologists Without Borders to a real organization is coincidental.
My last essay ended with a census of my readership: North Korea, Syria, a pirate ship off the coast of Yemen, and ten or twenty Chinese Googles.
I can now report a human. His name is Ali. I sent him the link at night, and the next afternoon he sent back a review. He loved it. He hadn’t realized the interviews are all done on Zoom now. What a loss, he said. Then he thought about it some more: although, he guessed, it was expensive.
The AAMC needed a survey to get there. Ali needed four sentences.
My wife’s position is unchanged.
II. The Gunner
Ali thought it was a loss, so I told him what we lost.
Every medical school class has a gunner. For the pirates: a gunner is the student who treats medical school as a contest and intends to win it. I say this with respect. A gunner knows your patient’s potassium before you know your patient’s name.
A classmate of mine at Michigan wanted dermatology. Dermatology is about the hardest residency to get, for reasons every doctor understands: the pay is good, the hours are sane, and skin rarely has an emergency at 3 a.m.
He took no chances. He applied to fifty programs and flew to every one that would have him.
III. The G-Wagen
This was the old way. Every invitation meant a plane, a hotel, and the suit.
He paid the application fees. He paid Southwest. He paid Spirit. He paid a series of hotels selected for price.
By my estimate he spent a G-Wagen’s worth. I have no evidence of the G-Wagen. I had no evidence of the yacht either, and I stand by the yacht.
For the same money he could have bought the G-Wagen and driven it to the interviews. He would have pulled up to every dermatology program in America looking like a man who had already finished one.
Residency is decided by a computer. You rank the programs. The programs rank you. On a Friday in March the computer reads both lists and tells you where you live now.
The computer considered fifty programs, a G-Wagen’s worth of travel, and every city Southwest serves. It sent him to the University of Michigan.
He was a medical student at the University of Michigan. He was already there. He could have walked.
I know the route. I walked it once, in a black suit.
I would like to feel superior about this. But I flew all over the country for medical school interviews, got into the one school I could walk to, and declined the rest. I did the same thing. He did it in a nicer car.
V. The Closet
I have never written about my own Match Day.
I did not want to go to residency. I have said elsewhere what I wanted, which was to start a company out of a childhood friend’s closet in San Francisco. He’s the only person I’ve known that I can sincerely still call a friend even after starting a company together, spending a year coding shoulder to shoulder during most of our waking hours, while also sharing rent for studio apartments in SF and NYC. I decided to take another “gap year”, which turned out to be the start of a career in gap years, after seriously considering a career in surgery during a mind-changing medical school surgery rotation (that deserves its own story).
The computer does not match to closets.
I did not have the courage to submit zero applications. That would have been obvious. So I applied to four programs in a specialty I had no interest in. I chose radiology. Although I admire visual art and consider myself someone with decent aesthetic taste, my mind tends to reach first to text and numbers when solving a problem before taking a visual approach.
I put on the black suit and interviewed at all four, with no serious intention of attending any of them. My classmate wore the suit for jobs he wanted. I wore it for four I did not.
In the end I decided to hold off on residency for at least a year. It turned out to be a year.
We all carried pagers then, the size of bricks. I once dropped one in the toilet in University Hospital and was under the impression that I had to fish it out and return it to security in order to be issued a new pager. But that deserves its own story too. Anyway, I knew what would happen when the algorithm finished its work. Everyone who matched would get a page congratulating them. Everyone who did not would be summoned to the dean’s office, slapped on the ass, and hustled into an unfilled residency spot in a specialty that may or may not be related to the applicant’s original interest. Bottom line is, you have a chance to redeem yourself and eventually become a licensed physician in a residency program.
I am no idiot. I knew what was coming. An email arrived silently in my inbox, telling me that I had not matched. Surprise, surprise. It was the inevitable outcome of my own making.
I turned off my pager and my phone. Then I did the only thing I could. I celebrated wildly with my friends, hugging and kissing, as though I had just landed a dermatology residency at an academic medical center with floors of perfectly reflective marble, and where the waiting lists are so long that patients perish outside on the front steps waiting for their first appointment. YES WE DID IT!!! I screamed in feigned ecstasy.
After about five minutes of celebrating, the receptionist huffed up the stairs to the small windowless room where my cohort of medical students was huddled.
“Omar, honey? You didn’t match. You need to come to the dean’s office, honey.” I quickly avoided eye contact with all of my classmates and darted to a remote bathroom that I reserved for emergencies like these.
My digestion is, overall, OK. On that particular day I made my way quickly to a bathroom deep in the bowels of the Medical Science II building and engaged in a continuous, fifteen-minute episode of watery diarrhea. It was catharsis in a gastroenterologic sense. The whole time I was trying to silence my pager. I had turned it off. It kept notifying me that I had not matched, even as I ripped out the AA batteries. I prayed that the woman who had huffed her way through a mile of indoor med sci labrynths wouldn’t track me down by my scent and walk into the bathroom. Omar, honey? I could imagine her voice echo in the bathroom.
To make a long story short, I ended up learning to write iOS apps the old-fashioned way, which is a human actually writing the code. I had help from a friend, the only other physician coder I know. He is also a University of Michigan Medical School alumnus, an electrical engineer, and one of the most gifted programmers I know. He donated his time to meet me in cafés around Parnassus and in the UCSF medical library, where he helped me debug my GET and POST API calls. I owe him, at least, a great deal of gratitude for all that time and help.
I did that for as long as I could, which was one year after medical school. Then I needed a paycheck, and I enlisted as a human battering ram for a local internal medicine residency program, where I met some of the most uniquely unforgettable and gifted people I’ve known: at St. Mary’s Hospital in San Francisco (now UCSF Health) and later at Highland Hospital in Oakland.
I am an internal medicine physician.
VI. Portland
An interruption.
This just popped into my brain.
Later I did it again, applying for a clinical informatics fellowship at Oregon Health & Science University. It is a forward-looking university in one of my favorite cities. In reality, I ended up choosing UCSF. I was lucky enough to have many great options. In a parallel universe I went to Portland. The memory of a bright morning ride on the Seilbahn (Portland aerial tram) is a happy and lasting one.
I finished my shift at the county hospital in Oakland at 11 p.m. I got in my car with my white coat still on, drove to Oakland International, and flew to Portland. I checked into a hotel room that cost between $250 and $300 a night and slept in it for about two hours. That is roughly $140 per hour of sleep.
The morning after the interview I woke at 3:30 for the flight home. I woke with the hardest direction I have ever had. I am dictating this part, and the software has chosen the word direction. I am leaving it. It was the ordinary morning kind. Only the hour was unusual.
At security the scanner beeped. The TSA agent pointed to his screen. It showed the outline of a person, and on the outline, over my direction, a large red dot.
“I’m going to have to pat it down,” he said.
I was patted down without objection or resistance. Then I was on my way to the gate, to sip Portland-roasted coffee and wait for my flight back to Oakland.
Since then, when I go through airport security, I put my hands at my waist where they are clearly visible and ask the agent: do you need to pat me down?
Years later I told this to my family. Half of them are physicians. The other half are lawyers. My father snorted an insolent snort and said the TSA guy probably liked it.
I thought: he better have.
What was I saying?
VII. The Loss
So what did we lose?
Today’s gunner applies to fifty programs from his apartment. He does fifty interviews in one chair. On the screen there is no stool, and everyone is the same height. The camera shows him from the chest up. I was seen on a screen once during an interview trip, and the framing was different.
He spends nothing. In March the computer tells him he is staying where he is, and he has gone nowhere to find that out.
This is better. For decades we sent applicants around the country in black suits, on borrowed money, so that a computer could tell some of them to stay put. Ninety percent of applicants wanted the option of skipping it. I would have wanted it too.
The only thing lost is the story. Nobody pats today’s applicant down. My classmate has a story with fifty cities in it, and he paid a G-Wagen for it. I have Portland, and I paid for that too. That is experience.
His story cost me nothing. I just know the guy. That is reference.
VIII. Intellectual Property
I ended my message to Ali with a warning. If he writes a story about this before I get around to telling it, I’ll sue. I’ll sue him, and I’ll sue my classmate. For plagiarism.
I see the weakness in the case against my classmate. It’s his life. He lived it first, at great expense, and he has the receipts.
My position is that he only lived it. I’m the one who told somebody.
IX. Coda
The stopwatch is still running.
Experience is airport security with a 3:30AM direction. A machine can describe one. It has never been patted down for one.
Reference is a man who flew to fifty cities to end up where he started. I didn’t have to make him up.
I had just interviewed at the University of Michigan Medical School. I had not yet been accepted or rejected. I can say what follows because Michigan was my first choice then, and it would still be my first choice if I were applying today.
After an interview it is customary to write a follow-up letter. You thank the school for the invitation to take time off from your work and your family, spend a couple of grand you do not have, fly somewhere, and roll the dice. I flew to many of these, all over the country. For this one I was lucky. I was already an in-state undergraduate, so I did not have to fly. I walked across Ann Arbor from my apartment to the hospital in a black suit, alongside a group of other applicants in black suits. We looked like itinerant funeral attendees.
I am told this is now done mostly by video. The Association of American Medical Colleges recommends it, on the grounds that the old way cost applicants hundreds to thousands of dollars and pulled them away from school and work. They surveyed the applicants. Ninety percent wanted the option of staying home.
So I would like to recognize the sacrifice of everyone who did it in person, and everyone who still does. For college. For medical school. For graduate school. For residency. For fellowship. A person can do this five times in one career. We blew a great deal of time and money walking around in those stupid dark suits, and nobody surveyed us.
So I wrote the letter. I thanked them for the opportunity to interview at my first-choice medical school.
Then I started to complain.
II. The Stool
One of my interviewers was a small man from Thailand. He sat on a stool. It was the tallest stool I had seen up to that point in my life. The seat was about halfway between the floor and the ceiling.
He invited me to sit in a chair. It was the kind of chair your neighbor gives you once their grandchildren have outgrown it: toddler furniture that belonged first to their kids, then to one grandkid, then made the rounds of the other grandkids, and then came to you.
I sat in it. I looked up, in the general direction of the ceiling, and he interviewed me.
This is the custom. You travel the country racking up tens of thousands of dollars in debt in order to sit beneath an interviewer at his preferred altitude and explain, with glee, how badly you want to be a doctor and save the world and do something useful for society. I explained it with glee. I explained it to his shoes.
What was I saying?
III. Eye Level
In medical school they record you. They record you constantly, and then they play it back and point out every stupid thing you did on camera. Feedback, feedback, feedback. In the process they make you a better doctor. A better human being, actually.
One thing they teach you is to sit down level with the patient, eye to eye. It has been studied. You do not spend one additional second in the room, but the patient feels as though you did. It is a peer-reviewed illusion.
Today’s applicants get this for free. On a screen there is no stool. Everyone is the same height.
I had not learned any of this yet. For me it was just common sense, in the form of a question: who the heck is this guy?
So I put it in the letter. Thank you for the opportunity. Your interviewer was hovering. I was nearly on the floor.
The next day I received my acceptance to the University of Michigan Medical School. Other schools I had flown to accepted me as well. I declined them.
That was the start of ten years as a Michigan student: college, then medical school, with a two-year stint in the Department of Microbiology doing Ph.D.-level research and coursework. It was also the start of my writing career. I have been thanking institutions and complaining about them in the same document ever since.
IV. The Stopwatch
I keep a personal stopwatch for humanity. It stops on the day it is no longer possible to tell the writing of David Sedaris from the writing of a machine. On that day, as far as I am concerned, humanity is finished.
I say this with respect. I have to make myself laugh in order to get through each day. There are many things in life I do not need to waste time explaining, and laughter is the therapy for all of them. It is the medicine. I have never met David Sedaris. Two of my siblings have. All five of us read him avidly. I am not picking on him. He is the benchmark because he is a genius.
A machine can produce beautiful text. It can be funny, moving, and very easy to believe. What it lacks is two things: experience and reference.
Experience is the toddler chair. A machine can describe one. It has never looked up from one.
Reference is the other thing. When Sedaris writes, he is calling out people from his life. He does it in a funny way, often in an embarrassing way, and, I am assuming, in a consensual way. Also in an honest way, an educational way, and really a respectful way. The people are real. They can be reached for comment.
What was I saying?
V. The Readership
Without a readership a writer is nothing. A writer without readers is a human text generator.
Sedaris has millions of readers. I picture him keeping the fan mail in a Rolodex, a literal, physical Rolodex, aboard his yacht, flipping through it as he darts across the Pacific: the beaches of Vietnam, Japan, Australia, New Zealand, Tonga, Hawaii. I have no evidence of the yacht.
I am blessed with anonymity. Nobody knows who the hell I am. This empowers me. Occasionally my website has a visitor from North Korea, or from Syria, or from a pirate ship off the coast of Yemen. Now and then, an AI bot. I picture ten or twenty Chinese Googles crawling the internet, processing information, and arriving, eventually, at me.
That is probably the extent of my readership. It gives me the strength and the will to keep writing. Their feedback is extremely important to me.
VI. The Secret Sauce
The real secret is my wife.
I can say this because she is the smartest person I have ever known. She is afflicted with dyslexia, which means that she is illiterate and cannot read. She has never read anything I have written.
This is the secret to our harmonious marriage, our great sex life, and my career as a writer: we can’t even talk. And I have to talk to somebody. So I write it down, post it to a public website for the pirates and the crawlers, and then I go back to my wife.
Sedaris, I assume, gets consent. I have a more efficient arrangement.
VII. Coda
I dictated this essay. The transcription software spelled David Sedaris seven different ways, one of them correctly. The stopwatch is still running.
At the end I repeated my thesis out loud, to make sure I still had it. Experience and reference. The machine listened carefully and wrote down: experiencing our friends.
It is a better definition than mine. It has no idea why.
Thank you for the opportunity.
Addendum
Before posting this essay, I asked my wife for her consent. She said yes. She said it in English, in the English language, very clearly.
After she realized that I had posted it, she clarified that by yes, she had meant no.
I attribute this to the dyslexia.
Sedaris, I assume, gets consent. So did I, briefly.
I wrote above that the people in an essay are real and can be reached for comment. She has been reached. The comment is no.
As an undergraduate at the University of Michigan, before clinical practice had a chance to teach me what a relative value unit was, I spent a summer doing biotechnology research at the Finnish Forest Research Institute, known as Metla. I went for the science. I came home with a lifelong respect for Finnish culture and a love of sauna that has outlasted most of what I learned in organic chemistry.
I am now reading a book on the history of sauna. For centuries, it says, the sauna was where Finns gave birth, stored food, compounded remedies, and saw patients. Delivery room, pantry, pharmacy, clinic. One room, one stove, no billing department.
This reminded me of a public bath in Vienna, where I once tried to leave the sauna at the peak of the Aufguss. The sauna master blocked the door and yelled “Nein!!!!” while vigorously swirling a towel, his penis and his considerable abdomen passing within striking distance of my face. The Aufguss continued.
My former cabin mate and sauna buddy, Oskar Rausch, insists the Viennese did not invent this, and that the historical record supports him. I have not checked. What follows is his account.
by Oskar Rausch
This is a work of satire and fiction.
I. The Refill
In the winter of 1387, in a parish whose name survives only as a smudge, a farmer named Perttu walked naked into the village sauna and asked for a refill of his lisinopril.
The sauna was the parish’s hospital, pharmacy, maternity ward, and smokehouse. Perttu had been born on the lower bench. Several hams were currently recovering in the rafters.
The pharmacist, also naked, consulted the formulary. It had three entries: Sauna. Liquor. Tar. Below that, in the same hand: If these do not help, the disease is fatal.
“We don’t carry lisinopril,” he said. “It won’t be derived from Brazilian snake venom for another six hundred years. I can offer you tar.”
“Is tar effective?”
“Nobody has ever come back to complain.”
This was true. The follow-up period in medieval Finland was about thirty-five years, and the adverse event reporting system was a hole in the ice.
“Fine. Tar.”
“Do you have a prescription?”
II. The Prescriber
“So,” said a voice from the bench above. “You need a prescription.”
The doctor had been up there since Tuesday. In a sauna, bench height is seniority, and he had not come down for a patient in years.
He performed the exam without moving. “Alert. Oriented. Red.” He considered the differential. The patient was in a sauna, so the redness was inconclusive. Blood pressure could not be measured, the cuff being five centuries away, which meant that by the standards of the day Perttu did not have hypertension and never would.
“There’s nothing wrong with you,” the doctor said. “I’m prescribing more sauna.”
“I’m in the sauna.”
“Then it’s working.”
Perttu said this was incompetence, and that he would sue them both.
III. Counsel
The word “sue” had not finished echoing when a lawyer emerged from the steam in the corner. He had been there the whole time. He billed by the ladle.
“Has anyone in this sauna been injured by tar?”
His practice faced immediate obstacles. He had no business cards and nowhere to keep them, so he carved his name into a birch whisk and handed it over. Discovery was completed in four seconds, as no party was concealing anything. And he disclosed a conflict of interest: he was the doctor’s patient, the pharmacist’s customer, and had been born in this room.
In the far corner the cupper, mid-procedure with a cow horn on a man’s back, asked who was going to pay for the horn. Nobody answered him. Nobody ever does.
IV. Public Order
The bailiff arrived to restore order. He had no badge, no uniform, and no pockets. He established authority the only way available, by sitting on the top bench without flinching.
Frisking was complete on arrival. The irons had been hanging by the stove and were now the temperature of the stove, so applying them would have been a second offense. He informed all parties of their right to remain silent, which, being Finnish, they had been exercising since birth.
Then the judge appeared through the steam. He had no robe, only the ladle, which he banged twice on the bucket. The jury was twelve farmers who were already sitting there. Several believed they were still just having a sauna. One was.
V. The Ruling
The expert witness was the proverb. Sauna, liquor, tar. The doctor had prescribed sauna. The pharmacist had offered tar. Nobody had offered the liquor, which the court noted with concern and corrected immediately.
The judge ruled from the bench, the upper one:
The doctor was found competent, on the evidence that the patient was still alive.
The pharmacist was fined one barrel of tar, payable to himself.
The lawyer was awarded his fee in birch whisks and was whipped with it.
The cupper got his horn back.
The plaintiff was sentenced to more sauna.
Perttu stood up to leave in protest.
The bailiff rose, blocked the door, took up a towel, and began to swirl it with great vigor, his authority and his abdomen passing within striking distance of the plaintiff’s face.
“EI!!!!”
Perttu sat back down. The löyly continued.
Historians of the Viennese Aufguss date their tradition to the twentieth century. They are off by six hundred years and one bailiff.
VI. The Itemized Statement
Because this was 1387, the bill arrived the same day, fit on one page, and could be paid in tar.
S00.LÖYLY
Sauna, therapeutic, unlimited
No charge
T14.TAR
Tar: topical, oral, spiritual
1 ladle
Y90.VIINA
Liquor, court-ordered
On the house
Z02.RED
Physical exam, from upper bench
1 fish
Z65.LAW
Legal counsel, per ladle (×40)
40 birch whisks
W55.HORN
Cupping horn, interrupted
Disputed
Z99.EI
Attempted exit during löyly
1 towel, to the face
TOTAL DUE
1 barrel of tar, whenever
At the bottom, in small print: No late fees. No collections. Balances unpaid after thirty-five years are forgiven, along with the patient.
Perttu paid in full. His blood pressure was never measured. He lived, by all records, exactly as long as everyone else.
At MegaBulk Warehouse Club, members can buy a 48-pack of rotisserie chickens, a hot tub, a casket, and now, a brand new kitchen, installed by MegaBulk’s Preferred Partner, Boulderdash Surfaces & Demolition.
“We vet every partner,” says a MegaBulk representative, gesturing at a vetting process consisting of a single Post-it reading has truck?
Boulderdash’s crew arrives promptly, three to nine business weeks after the scheduled date. Removing old countertops is a delicate art, and Boulderdash approaches it like a monster truck rally. “The old laminate fights back,” explains lead installer Dwayne, who has never once used the word “pry” and considers a sledgehammer a precision instrument. When the dust settles, the new counters gleam, and the wall behind them features two holes large enough for a family of raccoons to rent.
“That’s not damage,” Dwayne says. “That’s an open-concept wall.”
The homeowner calls. And texts. And emails. With photos. With more photos. With a ruler in the photos for scale. Boulderdash’s project manager, Mickey, receives each message the way a monk receives a passing breeze: with total serenity and no response. Insiders say Mickey has achieved a level of detachment the Dalai Lama called “a bit much.”
Then, one day, everything changes. The homeowner tells the finance company the job isn’t finished.
Within four minutes, Boulderdash’s entire staff materializes, like Victorian ghosts summoned by the smell of an unpaid invoice. Mickey, who could not locate a text message from April, can now recite the homeowner’s balance to the penny, along with his blood type. The billing department sends a letter warning that unless payment arrives in ten days, they will send him to collections, sue him, and personally revoke his right to buy 48 rotisserie chickens at once.
“We take customer satisfaction very seriously,” says Boulderdash’s credit manager, “in the sense that we’ve noticed it’s legally required before we get paid.”
Five months later, the homeowner hires his own guy, who fixes the wall in an afternoon and leaves without breaking anything, a feat Boulderdash is investigating as possible witchcraft.
MegaBulk has renewed the partnership. “Members love the convenience,” the spokesperson says, already picking out a casket for the next customer.
II. The Hip
For eleven years, Mickey’s hip had been filing complaints. Mickey responded the way he responded to all complaints: with serene, unbroken silence.
Twelve physicians told him the same thing. His BMI of 57, his breakfast of three gas station taquitos, and his cardio routine of walking from the couch to the door to ignore a customer were all contributing factors. Mickey thanked each of them, then left two large holes in their waiting room drywall on his way out, purely out of habit.
Finally, he could no longer get out of his truck without a forklift. Surgery was scheduled.
His surgeon was Dr. Lyle Fenwick, a man who once loved medicine and now loved only the four minutes in the parking garage before his shift. Dr. Fenwick was tragically afflicted with sobriety, meaning he had to experience every second of his life fully, including the part where his own hospital billed him $1,900 for an inhaler that literally costs four dollars in any Vietnamese pharmacy. He’d had an asthma attack about it. They billed him for that too. He had paid his health insurance premium on the first of every month for 37 years, missed exactly one, and was now fighting the foreclosure of his house through a customer service chatbot named Skyler.
III. The Pre-Op
Mickey never actually met Dr. Fenwick before surgery. Surgeons no longer meet patients. All that unpaid talking, touching, and listening has been outsourced to physician assistants, nurse practitioners, and a rotating cast of Caribbean medical students on unpaid shadowships, who are permitted to observe but not to sit, speak, or eat.
His exam was performed by Kyle, PA-C, who asked Mickey to show him where it hurt. Mickey cupped his hand around the side of his hip in the universal C-sign, the most famous gesture in orthopedics.
Kyle nodded and typed: Pt makes C-sign. Hip.
Then Kyle’s lunch arrived, and he never came back.
Dr. Fenwick had been up until 4 a.m. composing a strongly worded letter to his mortgage servicer, which turned out to be a strongly worded letter to Skyler, which ended with Skyler asking him to rate his experience. He arrived in the OR at 7 a.m., powered entirely by spite and a vending machine Mountain Dew, and glanced at the chart.
Pt makes C-sign. Hip.
“C,” he muttered. “Countertop?”
The medical student opened her mouth, remembered she was not permitted to speak, and closed it.
The old hip came out the Boulderdash way. Witnesses describe the technique as “enthusiastic” and “audible from the cafeteria.” Dr. Fenwick then turned to install the new one, a custom slab of imported sintered stone, honed finish, with an undermount sink. It was backordered. Before he could ask about a delivery date, his phone buzzed. It was Skyler.
He stepped out to take the call. He did not step back in.
“Looks great,” he said, already in the parking garage. “Tell him to call the office if he has any issues.”
IV. Mickey v. Fenwick
Mickey woke up, looked at his incision, and felt a draft.
Where his hip joint used to be, there was now a hollow socket, a few loose staples, two holes large enough for a family of raccoons to rent, and a faint echo when he coughed.
He called the surgeon’s office. And texted. And emailed, with photos, a ruler in each one for scale. The office received each message with total serenity and no response. The receptionist had reached a level of detachment that Mickey, deep down, recognized and respected.
Then, after five months, a reply arrived. Dr. Fenwick’s office was pleased to offer Mickey a complimentary redo operation, at no charge, performed by the same surgeon, in the same OR, at a time convenient for Dr. Fenwick.
Mickey considered it. He pictured the Mountain Dew. He pictured Skyler. He pictured the parking garage, and the four minutes Dr. Fenwick loved more than anything on earth, and the word “Countertop?”
He wrote back that he was deeply grateful for the generous offer and would have to decline.
So he called a lawyer instead.
Walt Kowalski Jr. had known Mickey since Sunday school, and the two had stayed close through college, where Walt majored in Business Communications and minored in Cornhole. After graduation, Walt answered an ad on the back of a Ticketmaster receipt and enrolled at the St. Barnabas Island School of Law & Parasailing, the Caribbean’s only law school, and possibly the world’s.
The campus was beautiful. Classes were held on a catamaran. Moot court took place at a swim-up bar, and the bar exam was, technically, at a bar. Over four years, Walt spent $830,000 in tuition, most of it on mandatory “Torts & Tiki” seminars and a required textbook that turned out to be a laminated drink menu.
Only after graduation, while framing his diploma (printed on a beach towel), did Walt read the fine print. His degree made him ineligible for admission to the bar in all 50 states, Puerto Rico, Guam, the U.S. Virgin Islands, and “any present or future U.S. territory, including those on the Moon.”
Walt was undeterred. A law license, he reasoned, was just a piece of paper, and he already had a beach towel. He read the law obsessively, mostly from Wikipedia, YouTube, and the backs of parking tickets. He gave his friends legal advice at barbecues, always prefaced with “I’m not a lawyer, but I did spend $830,000 becoming one.” And whenever a judge didn’t ask too many questions, he represented Mickey in court.
His record was mixed. He once got a speeding ticket reduced, though it was later revealed the officer simply felt sorry for him. He successfully argued that Mickey’s truck was not parked on a sidewalk because “sidewalks are a social construct.” And he won a small claims case against a vending machine, which failed to appear.
Walt’s own legal history was richer than his client list. He had been arrested eleven times for Driving Under the Influence of Stupidity, a charge Michigan created specifically for him after he drove through a car wash with the windows down “to save time.” He had two convictions for Operating While Incompetent, the first for merging onto I-94 in reverse because “the on-ramp was facing the wrong way,” the second for parallel parking inside a Taco Bell. His most recent arrest, for Reckless Negligence, came after he used Google Maps to navigate to his own court date and arrived at a lake.
Walt represented himself every time and lost every time, which he considered valuable trial experience. “Every great lawyer has a few convictions,” he told Mickey. “Mine just happen to be literal.”
Walt had also, briefly, served his country. After the bar rejections came in, he walked into an Army recruiting office in Ypsilanti and volunteered for the only position he felt his education had prepared him for: human battering ram. The recruiter explained that the Army did not have such a position. Walt explained that he had spent $830,000 learning to argue, and the Army should be grateful he was offering his head instead. To demonstrate, he ran full speed into the recruiting office door, which was a pull door.
He was not enlisted, but he was invoiced for the door. He contested the bill pro se and lost, and the door now hangs in the St. Barnabas alumni hall as the school’s most distinguished achievement. “I still consider myself a veteran,” Walt likes to say. “Of the door.”
He ran his practice from the back of a MegaBulk tire center, under a hand-painted sign reading WALT KOWALSKI JR., ATTORNEY-ADJACENT. Consultations were free. Representation cost a case of Labatt.
“We’ll sue,” Walt said. “Nobody leaves a man with a hole and walks away.”
The case went to trial in Washtenaw County. Representing Dr. Fenwick was Priscilla Vance, Esq., who had never lost a case and had never once smiled indoors.
“Mr. Mickey,” she began, “you claim my client left your hip unfinished and ignored your complaints for months. Is that correct?”
“Five months,” Mickey said. “Nobody called me back. It’s unprofessional.”
Priscilla nodded and handed the jury a binder.
“Exhibit A: 214 unanswered texts from Mr. Mickey’s own customers, each with photos and a ruler for scale. Exhibit B: Boulderdash’s standard work order, signed by Mr. Mickey, in which his company promises to, quote, perform all work in a professional manner and within industry standards.”
She let that sit.
“Mr. Mickey, in your professional opinion, what is the industry standard?”
Mickey thought about it honestly, which was a mistake. “Well. You take the old one out. Usually there’s a couple holes. Then the customer calls for a while. Then they stop calling. Then you send the bill.”
“And how long does the customer call for?”
“Five months, give or take.”
Priscilla turned to the jury. “Ladies and gentlemen, my client removed the old part. He left a hole. He ignored the calls for five months. Then he sent the bill. By the plaintiff’s own sworn definition, my client performed this surgery within industry standards.” She paused. “Frankly, he didn’t even chip the seam. He exceeded them.”
The jury gasped. Walt quietly closed his legal pad, which was a Taco Bell menu.
“Furthermore,” Priscilla continued, “the plaintiff now has an open-concept pelvis, which is very desirable in today’s market.”
The jury deliberated for nine minutes, most of it spent choosing a sandwich place. Verdict: for the defense.
V. The Itemized Statement
Before Mickey could leave the courtroom, Judge Harold P. Ambrose, 81, waved him up to the bench. Judge Ambrose had presided over Washtenaw County for 46 years and had long ago stopped distinguishing between his courtroom and his back porch.
“Son,” he said, giving Mickey a hearty slap on the back that whistled straight through his hip socket, “no use crying over spilled milk. Now you pay that doctor on time, you hear? Nobody likes a man who doesn’t pay his bills.”
“But Your Honor, he didn’t finish the—”
“On time,” said the judge, and banged his gavel, which turned out to be a corn dog.
A week later, just as his scars were starting to close, the envelopes arrived. Then more envelopes. Then a man from a law office in Southfield handed him an envelope, apologized, and handed him a second envelope for the cost of delivering the first.
Each bill was meticulously itemized:
Z99.HOLE
Removal of hip, existing, with enthusiasm
$31,200.00
Z99.HOLE.2
Installation of hip, new (not performed; billed for preparedness)
$28,400.00
R29.C
Interpretation of C-sign by physician assistant, partial
$1,150.00
R29.C.1
Interpretation of C-sign, remainder, after lunch
$1,150.00
W00.SKY
Surgeon on hold with mortgage chatbot during procedure, per minute (×212)
$18,656.00
Y93.STUD
Observation by Caribbean medical student, silent
$2,900.00
Y93.STUD.SPK
Medical student almost speaking
$4,100.00
T88.SINK
Undermount sink, backordered, location unknown
$1,349.00
Z71.ECHO
Ongoing acoustic properties of hollow socket (monthly subscription)
$89.99
Z00.NOPE
Phone calls to office, unanswered (×47) (courtesy adjustment)
$0.00
Z99.LATE
Late fee for failing to pay within ten days of receiving this bill, which was mailed eleven days ago
$4,000.00
TOTAL DUE
$92,694.99
At the bottom, in small print: Payment is due within three (3) business days of service. Balances not paid within this window will be referred to collections and accrue interest at 79%, compounded weekly. We take patient satisfaction very seriously.
Mickey checked the date of service. He had spent six weeks in the recovery ward, mostly because nobody had come to discharge him. The three-day window had closed while he was still under anesthesia.
The account was sold to Ironclad Recovery Partners, then to Liberty Debt Solutions, then to a man named Gus who operated out of a van behind a Dairy Queen in Taylor. Each new owner sent a fresh letter.
Week 1
Ironclad Recovery Partners
$165,924.03
Week 2
Ironclad Recovery Partners
$297,004.01
Week 3
Liberty Debt Solutions
$531,637.18
Week 4
Liberty Debt Solutions
$951,630.55
Week 5
Gus (van, Dairy Queen, Taylor)
$1,703,418.69
Week 6
Gus (van, Dairy Queen, Taylor)
$3,049,119.46
FINAL AMOUNT DUE (plus $35 convenience fee if paid online)
$3,049,119.46
The last letter came from Gus himself, handwritten on a Dairy Queen napkin: Pay in 10 days or we cancel your MegaBulk membership. Also your hip. Respectfully, Gus.
Mickey sat on his couch, holding the stack. For the first time in his career, he understood what it felt like to receive a demand letter from someone who had left two holes in your life and never come back to fix them.
VI. The Hollow
That night, Mickey lay in bed, listening to the wind whistle through his hip socket, and wondered how the world could simply not care.
A man had trusted a professional. The professional had shown up distracted, done damage no competent person would do, and walked away without a word. Mickey had called. He had texted. He had sent photos with a ruler for scale. Nobody answered. Nobody even seemed to notice. And then, the moment money was owed, everyone noticed at once, and they all had his phone number.
“How can people treat each other like this?” he whispered into the dark.
The house said nothing. The two holes in his drywall said nothing. But somewhere in the back of his mind, a memory surfaced: an April afternoon, his phone buzzing on the dashboard of his truck, a homeowner’s name on the screen, a photo of a wall with a ruler held up beside it.
He had let it ring. He had taken a bite of his taquito. He had thought, I’ll get to it.
Mickey lay very still for a long time.
Then he picked up his phone, scrolled back five months, and, for the first time in his entire career, texted a customer back.
Sorry about your wall, he wrote.
The message delivered. No response came. Mickey understood. He would have to wait.
Outside, the wind passed through the hollow in his hip and played a single, perfect note, which the hospital billed him for the next morning.
This is what happens when you trust a Costco “special vendor” (W.S. Townsend Company dba MKD Kitchen and Bath “MKD” at 106 Oliver Dr., Marshall, MI 49068, License No. 2102123598) to remodel your kitchen.
Funniest thing is that they’re asking me for money.
Well done. Reminds me of the Russian folk wisdom: “Measure three times, cut once.”
Quality stone made in Spain. Installation botched in the USA. MKD: the pinnacle of demolition.
Entitlement: falsely believing that customers are going to pay you just because you send an invoice — no matter how crappy your work is, how lacking your communication, and how poorly you run a business.
I love paying people for their hard work. When they actually earn it.
If a doctor treated their patients the way MKD treats their customers, they would be imprisoned, de-licensed, and shamed. In the world of Costco “special vendors” though, it’s apparently another job well done. That’s the high bar of Costco quality.
If you can’t build it, threaten your customer with legal action, collections, and worst of all — revocation of their Costco cards. Good thing I already shredded mine. That’s the MKD way.
If you paid your lawyers half of what you pay your human wrecking balls, “project manager” harassers, and “credit managers,” you would spare yourself a lot of unnecessary and avoidable problems. Good legal advice pays for itself.
By Omar Nabil Metwally, MD
Internal Medicine Physician First published 30 August 2026 · Revised and expanded with references
One of the most important classes that I attended as a Clinical Informatics Fellow at UCSF was a course on clinical research. This reflection surprises me in hindsight because I long associated “Clinical Informatics”, which was then a new medical specialty (I was in UCSF’s second class and their third Clinical Informatics Fellow), with the intersection of technology and patient care — a niche for technologically-affine physicians capable of transforming healthcare, if only (so the reasoning) they connected with the right decision makers, got on the right Teams calls, and joined the most elite mailing lists. I was not expecting to sit down almost 10 years later to write a blog post about what I then considered the driest of subjects: biostatistics.
In retrospect, I had a lot to learn, and I could have learned those valuable lessons with a more open and receptive mindset. I consider Professor Pletcher’s course significant in two regards. First, it gave me an opportunity to think deeply about the tests that doctors (especially non-surgeon physicians) routinely order on behalf of their patients and are expected to interpret and act upon correctly. Second, it planted the seed for the realization, many years after my time at Parnassus, that the specialty of Internal Medicine boils down to one concept: a priori likelihood.
There are two types of doctors that take care of people: physicians and surgeons. Physicians — doctors like internists and pediatricians — do a bulk of their work in the cognitive realm, which often takes the form of making a short-list of diagnoses and honing in possibilities (in medical jargon, this is called making a differential diagnosis). This is in contrast to surgeons, whose work tends to be more operative in a hands-on, physical sense than a physician. A physician who does not understand the tests they are ordering, the diagnostic consequences of their choice of test, and how to interpret the results, is like a surgeon without the physical skills necessary to perform a particular operation. I’m deliberately over-simplifying to make the point that despite the fact that test ordering and interpretation has traditionally been a core competency of physicians in general, I encounter an alarming number of physicians, new and experienced alike, who lack the skills to understand what they’re ordering (or not ordering) and how to correctly interpret positive and negative results. Equally alarming, and I suspect related, is organizational policies that narrowly prescribe diagnostic protocols in order to move a patient from point A to point B on the healthcare labyrinth — in the process, stripping physicians of what little autonomy they still have to exercise their clinical judgement.
The objective of this writing is to capture that lesson for any doctor who will ever order (or decide not to order) a test and be expected to interpret the result — if they are lucky to even have the choice.
The order that sounds correct
A middle-aged man presents with months of progressive hip and buttock pain. The pain is worst in the first hours after waking and after prolonged sitting. It wakes him at night. He has a years-long history of intermittent low back pain, a personal history of eosinophilic esophagitis, and a family history of autoimmune disease. Plain films show mild bilateral hip osteoarthritis — premature for his age. He asks for a rheumatology referral.
A reasonable-sounding plan: order an ANA and rheumatoid factor first. If negative, hold the referral. If positive, refer.
That plan has the shape of good medicine — screen, then escalate. It is also, for this presentation, close to backwards. Two errors are stacked inside it, and the second one is the more instructive.
Error one: the tests cannot see the disease
The clinical question here is axial spondyloarthritis. AxSpA is a seronegative spondyloarthropathy — and “seronegative” is not decoration. RF is expected to be negative. ANA has no association with the disease and appears nowhere in the ASAS classification criteria [1]. No result either test returns can move the probability of axSpA in either direction.
So the proposed gate was built from tests that cannot detect the condition being gated. A negative result would have been recorded as reassurance while carrying zero information about the actual question.
Error two: predictive value belongs to the patient, not the test
Here is the concept the wards tend to erode: sensitivity and specificity are properties of the assay. Positive and negative predictive value are properties of the encounter. The same ANA, on the same analyzer, means something entirely different depending on who is in the chair.
Do the arithmetic once and it inoculates you.
Worked example: the ANA in this patient
ANA is positive in roughly 20–30% of healthy adults at a 1:40 titer, and 10–15% at 1:80 [2]. Our patient has monoarticular hip pain with a mechanical mechanism, an axial pain pattern, and no features of connective tissue disease. Be generous and set the pretest probability of an ANA-associated disease at 0.5% — 1 in 200.
Per 1,000 similar patients
Test positive
Test negative
Disease present (5)
5
0
Disease absent (995)
~120
~875
Total
~125
~875
Assuming ~95% sensitivity and ~88% specificity at a 1:80 cutoff [3].
PPV = 5 / 125 = 4%. Twenty-four out of every twenty-five positives are false. A positive ANA in this patient is not a signal — it is noise wearing the costume of data.
And the costume is expensive. A positive ANA in the chart is never inert: it cascades to an ENA panel, a dsDNA, a “possible early connective tissue disease” note, a referral placed for the wrong reason, a patient reading about lupus at 2 a.m., and a label copied forward through every future chart review. The harm of a low-value test is rarely the test. It is the machinery the result switches on.
Worked example: the test that actually earns its place
Now run HLA-B27 through the same patient. Sensitivity is roughly 85% for axSpA — best established for radiographic disease, somewhat lower for non-radiographic axSpA and in non-European ancestries — with specificity around 90%, capped by a background allele frequency of roughly 6–8% in US populations of European descent (and higher still in Scandinavia) [4]. That yields LR+ ≈ 9 and LR− ≈ 0.15.
Given the inflammatory pain pattern, morning predominance, hip involvement, male sex, and family history, a pretest probability of 35% is defensible (pretest odds ≈ 0.54).
Negative: 0.54 × 0.15 = posterior odds 0.08 → ~7% post-test probability. Also decision-changing, in the opposite direction.
That is the signature of a test worth ordering: both results move you substantially, from an intermediate starting point. Note the dependency, though — run that same B27 on unselected back pain with a 2% pretest probability and the PPV falls under 20%. The likelihood ratio is a property of the assay; the usefulness is a property of your clinical reasoning.
And the tests that are neither: CRP and ESR
Worth naming because their prominence in “inflammatory workups” oversells them. CRP is elevated in only 40–50% of axSpA — a normal value carries a likelihood ratio near 1 and excludes essentially nothing. Their value here is prognostic (elevated CRP is one of the strongest predictors of radiographic progression, alongside baseline syndesmophytes and smoking [5]), as a baseline for treatment monitoring and ASDAS scoring, and for flagging infection. Diagnostically, they are close to inert. Order them knowing which job they are doing.
A worked example everyone lived through: the COVID home test
During the pandemic the federal government mailed free rapid antigen tests to any household that asked — well over a billion tests moved through federal programs before distribution wound down and was finally suspended in March 2025 [6]. Today the same tests sit on pharmacy shelves at $10–20 a box, and most people with a cough don’t bother. That shift is the thesis of this essay playing out at national scale — though the arithmetic contains a surprise worth sitting with.
At the Omicron peak, roughly half of symptomatic adults with acute respiratory symptoms actually had COVID: in CDC’s outpatient surveillance network, 56% of symptomatic adults tested positive during Omicron predominance [7]. Rapid antigen tests in symptomatic people carry a pooled sensitivity of about 73% and a specificity of about 99.6% [8]. Per 1,000 symptomatic people at 50% prevalence: 365 true positives against 2 false ones — a positive predictive value near 99.5%. The test was superb, and it was superb because of who was taking it.
Today, the same symptoms in the same person carry perhaps a 10% probability of COVID in a typical week — the rest is rhinovirus, RSV, influenza, and everything else — and closer to 3% in a deep trough between waves. Same assay, same operating characteristics. At 10% prevalence: 73 true positives against about 4 false ones — PPV around 95%. At 3%: PPV around 85%.
Here is where the intuition usually goes wrong, and it is the most instructive moment in this essay. The PPV fell — but nowhere near as far as it did for the ANA in our patient, whose PPV was 4% at low pretest probability. Why the difference? Specificity. The antigen test generates false positives at a rate of about 0.4%; the ANA at a 1:80 cutoff generates them at about 12%. When prevalence drops, a test with a fraction-of-a-percent false-positive rate degrades gracefully, and a test with a double-digit false-positive rate falls off a cliff. Pretest probability sets your ceiling; specificity determines how fast you fall from it. A positive home COVID test today is still probably real. A positive ANA in a patient without connective-tissue-disease features almost never is.
One more property worth internalizing: the sensitivity of a strategy is not the sensitivity of a test. A single antigen test on the first day of symptoms detects only about 60% of infections, but two tests taken 48 hours apart detect over 93% [9] — which is exactly why the FDA recommends repeat testing after a negative result [10]. Operating characteristics belong not just to the assay but to how you deploy it.
So why did universal home testing wind down? Partly for structural reasons that have nothing to do with epidemiology: the public health emergency ended in May 2023 and took the insurer free-test mandate with it, federal distribution stopped, and the tests now cost real money. But the clinical logic tracks the third question of this essay: will the result change what I do next? Under CDC’s unified respiratory-virus guidance, isolation is now symptom-based — stay home until improving and fever-free for 24 hours — regardless of which virus you have [11]. For a healthy, low-risk adult with mild symptoms, a positive test changes little about their own care.
And notice that the answer flips right back for the people in whom question three is still answered yes: anyone eligible for antiviral therapy, where a positive result starts a five-day treatment clock [12]; anyone about to sit down with an immunocompromised relative; healthcare workers and congregate settings, which the relaxed guidance explicitly does not cover. The newer over-the-counter combination flu/COVID tests sharpen the point further — in a high-risk patient, distinguishing influenza from COVID selects between two different antivirals. Same test, same prevalence, opposite recommendation — because the question being asked is different.
We ran a natural experiment on 300 million people, and the lesson was the one Professor Pletcher was teaching in a classroom on Parnassus: the test never changed. Who we gave it to, and what we planned to do with the answer, changed everything.
The three questions that replace the panel
The fix isn’t memorizing which panel goes with which complaint — panels are how we got here. It’s a habit, asked in order, before anything is ordered:
What disease am I testing for? Named and specific, out loud. Not “inflammatory something.” If you can’t name the disease, you can’t choose the test — tests are only interpretable against a named hypothesis.
What is my pretest probability — even crudely? “Under 5%, coin flip, or over 50%” is enough resolution to change behavior. The discipline is committing to a number before the result exists. A probability estimated afterward isn’t an estimate; it’s a rationalization.
Will either result change what I do next? If positive changes nothing and negative changes nothing, the test’s only outputs are cost, noise, and cascade risk.
Run the case through them. Disease: axSpA. Pretest probability: intermediate. Will ANA/RF change the next step? No — the MRI and the referral were indicated regardless of serology. Question three deletes the ANA in about four seconds. It also reveals something sharper: the problem wasn’t only which tests formed the gate. There should have been no gate.
Why good physicians make this error
This is not stupidity. It is a systems failure with a cognitive assist, and you should recognize the ingredients, because they will be your working conditions:
Order sets are frozen decisions. Someone decided once that ANA + RF = “rheum labs,” and the EHR has been re-making that decision on autopilot ever since. Every checkbox panel is a colleague from the past overriding your present reasoning — sometimes correctly, and you won’t know which times unless you look.
Covering is medicine at low resolution. An unfamiliar chart, an intermediary, a message queue. Pattern-matching to “joint pain → rheum panel” is what cognition produces under those constraints. The antidote isn’t heroic effort; it’s cheap heuristics that survive low resolution — which is what the three questions are.
“Baseline” is a thought-terminating word. Nobody argues with a baseline. But a baseline is just a test whose pretest probability nobody bothered to state.
And the sequel matters. When this reasoning was raised — politely, in writing — the physician reviewed the chart and ordered the appropriate labs within two hours. That responsiveness is the trait to emulate. The initial error was ordinary; the rapid update was excellent medicine. If you take a villain from this story, you’ve misread it. The villain is the reflex, and every one of us has it.
The distillation
A test result is not information about the patient. It is information about the patient conditional on why you ordered it.
The test doesn’t know who you ordered it on. You do. The entire interpretive weight of every result you will ever receive rests on the probability you assigned — explicitly, or by default — before you clicked the order.
Assign it explicitly. Every time. Ten seconds, and it is the highest-yield ten seconds in diagnostic medicine.
References
Rudwaleit M, van der Heijde D, Landewé R, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009;68(6):777–783.
Tan EM, Feltkamp TE, Smolen JS, et al. Range of antinuclear antibodies in “healthy” individuals. Arthritis Rheum. 1997;40(9):1601–1611.
Leuchten N, Hoyer A, Brinks R, et al. Performance of antinuclear antibodies for classifying systemic lupus erythematosus: a systematic literature review and meta-regression of diagnostic data. Arthritis Care Res (Hoboken). 2018;70(3):428–438.
Reveille JD, Hirsch R, Dillon CF, Carroll MD, Weisman MH. The prevalence of HLA-B27 in the United States: data from the US National Health and Nutrition Examination Survey, 2009. Arthritis Rheum. 2012;64(5):1407–1411.
Poddubnyy D, Rudwaleit M, Haibel H, et al. Rates and predictors of radiographic sacroiliitis progression over 2 years in patients with axial spondyloarthritis. Ann Rheum Dis. 2011;70(8):1369–1374.
US Department of Health and Human Services. Federal at-home COVID-19 test distribution program (COVIDTests.gov), January 2022; distribution suspended March 2025.
Kim SS, Chung JR, Talbot HK, et al. Effectiveness of two and three mRNA COVID-19 vaccine doses against Omicron- and Delta-related outpatient illness among adults, October 2021–February 2022. Influenza Other Respir Viruses. 2022;16(6):975–985.
Dinnes J, Sharma P, Berhane S, et al. Rapid, point-of-care antigen tests for diagnosis of SARS-CoV-2 infection. Cochrane Database Syst Rev. 2025;CD013705.
Soni A, Herbert C, Lin H, et al. Performance of rapid antigen tests to detect symptomatic and asymptomatic SARS-CoV-2 infection: a prospective cohort study. Ann Intern Med. 2023;176(7):975–982.
US Food and Drug Administration. At-home COVID-19 antigen tests: take steps to reduce your risk of false negative results. FDA Safety Communication, August 2022.
Centers for Disease Control and Prevention. Respiratory virus guidance. March 2024.
US Food and Drug Administration. Nirmatrelvir-ritonavir (Paxlovid) prescribing information: treatment of mild-to-moderate COVID-19 in patients at high risk for progression, initiated within 5 days of symptom onset.
Clinical details are composite and deidentified. Test characteristics are approximate, vary by assay, cutoff, population, and timing, and are cited to their principal sources above — the arithmetic is illustrative, and the habit is the point.
Notes from a two-day detour, and a brief field guide to the collapse
By Omar Nabil Metwally, MD
Written and published from a plane with its engines turned off on the runway, and no ETA.
“This is real. I am really here.”
— Gate B33, John F. Kennedy Airport
The Cast
The Bulbulmy father. A physician. Dreams of a home by the water.
Mom (Louly)awake since 6am, on the phone since midnight.
Methe son. The reason for the trip.
Siblings the chorus, texting from a safe distance.
Part One
The Detour
In which a family goes to New York for a piece of paper.
I
The Errand
We came to New York for a piece of paper. Military exemption paperwork, to be filed at the Egyptian consulate, in person, because some things still require a body in a room.
The consulate visit was brief and uncomplicated. That is the last sentence in this story that will be either of those things.
II
The Logic of a Physician
Before the consulate visit, I enjoyed kombucha at a cafe across the street. On the back of the can, a founder’s story: an infectious disease physician who met his wife on his way to the West African Ebola outbreak, and who now brews wellness without compromise.
Bulbul: What a wasted career. Kombucha is bland without the spice of pain.
⸻
Bulbul didn’t actually speak the above words. I am paraphrasing and synthesizing decades of wisdom that he’s instilled in me. Mom asked if I wanted milk in my cappuccino. Mom has not slept in a long time. Neither have I. It reminds me of how she used to order steak at Red Robin: well done but not too dry, medium well without the pink.
Bulbul says he’s always dreamed of a home by the water. I tell him I want to live in the mountains.
He suggests Tennessee. I ask him why Tennessee. If he’s ever been to Tennessee.
He says no. But I hear it’s gorgeous.
“Where then, if not Tennessee?” he asks. “Arkansas?”
And slowly I began understanding the logic of this man. My father. The logic of a physician.
That’s the thing about doctors. Too naive.
Later, on the way in, Bulbul slipped and called the consulate the pharmacy. He has not slept in a long time. Neither have I. I silently hope he wouldn’t walk inside asking for controlled substances.
III
The Cancellation
Then Delta began its slow work. A delay, and another, and another after that, each one announced with the confidence of a thing that would not happen again. At 2am the flight was cancelled outright. The ground staff had no information, no plan, and no visible theory of what an airline is for.
Mom had a system shutdown with her eyes open, holding the iPhone to her head with one hand, gazing at a crowd of angry Delta passengers trying to grasp what was happening to them.
By morning, Mom and Dad were still trying to find a flight to DTW. I was in a Lyft on the way to JFK.
NYC captives.
⸻
In a desperate act of love for one’s child, Mom bought the last ticket to Detroit, sacrificing herself and the Bulbul for their son.
And so they set out on their new life in Chinatown, wondering if they’ll ever see their children again. If anyone will remember.
IV
That’s Your Bed. This Is Mine.
Poor Mom. She was beyond exhausted last night. We had a really sweet Bengali Lyft driver, and Mom fell asleep listening to me talk to her.
The hotel — a nice and expensive SoHo hotel, for the record — is where Mom’s discomfort became obvious. She asked if there are bed bugs here.
The Bulbul asked with sincere concern: “What are you afraid of, rapists?”
And for a moment, I wondered if I should be afraid too. But I was too tired. I simply told the Bulbul, waving at Mom’s bed: “That’s your bed. This is mine.”
Sibling T: “Mom’s worst nightmare.” · Sibling U: “I told her to sleep at my place tonight.” · Me: “I told her the same.”
V
Morning in Chinatown
The Bulbul woke up at 10am, scratched his balls, and went back to sleep. Louly had been awake since 6am and on the phone since midnight.
I walk through vibrant, endlessly fascinating Chinatown — open air markets, tai chi in the park, the sounds, scents, and colors of life — and have coffee at a Vietnamese cafe. Between a Grab bike helmet and condensed milk cans, a hardcover book commands my attention: KIM JONG IL LOOKING AT THINGS. The Supreme Leader in a field of green wheat, generals arranged behind him like a hedge, all of them looking at things.
I flip through it while waiting for my coffee. It seemed like the correct souvenir from a week in which nobody in charge of anything was looking at anything.
Seriously though, Chinatown is endlessly fascinating. The mental stimulation was almost worth the pain.
⸻
VI
To the South
And now I am listening to the undulating breaths of the peaceful young Korean man taking me to freedom.
To the south. Where I am free to try, and to fail, and to keep trying.
VII
Gate B33, Terminal 4, John F. Kennedy Airport
This is real. I am really here.
Look closely and you’ll see a young woman with a travel pillow hugging her neck. She is crying. Not tears of sadness or fear — that was hours ago. These are tears of joy and relief.
And just out of view, to my right, is a veiled Arab woman wearing sunglasses and munching potato chips. She has witnessed true hardship in her life. Her family has lost everything, twice, and started over three times. To her, it’s another beautiful day in NYC, and yesterday’s detour an almost imperceptible inconvenience.
The paperwork, by the way, went through without a problem. It was the only institution all week that did what it said it would do, and it belonged to another country.
Part Two
The Failed State
In which the delay turns out not to be about Delta.
VIII
Not Enough Human Workers
For thirty-six hours I believed this was a Delta problem — a private failure, the kind you can be compensated for with a voucher. Then the article came through the chat.
Air traffic controllers had called out sick in unusual numbers. Thunderstorms did the rest. Equipment failed at a few hubs, apparently on principle. The FAA answered with ground stops at eight major Northeast airports, and the Transportation Secretary went on television to advise the nation to brace for more of the same, in the tone of a man reporting the weather rather than the forecast he himself commissioned.
The fix is on the books: 8,900 new controllers, hired by 2028. A promise scheduled to arrive several years after the problem — the national genre, really. In the meantime the system is short a few thousand people and runs on mandatory overtime, six-day weeks, and the private decency of individuals who have been given no other tools.
ATC staffing issue. There’s literally not enough human workers to safely direct air traffic.
⸻
That sentence should stop a country cold. It didn’t. It scrolled past between a sports score and an ad.
This is what a failed state looks like in a rich country. Not rubble. Not sirens. A terminal at 2am, fully lit, air-conditioned, staffed by people in uniform who have been instructed to know nothing, while four hundred citizens refresh an app that has also been instructed to know nothing. The infrastructure is immaculate. The thing it was built to do has quietly stopped happening.
They turned the engine off.
IX
The Marinade
By hour six a terminal stops being a place you pass through and becomes a room you live in. The lighting does not dim. The chairs are bolted at a distance calculated to prevent sleep. There is one working outlet for every forty citizens, and the man who found it first is now a landlord.
A gate agent has been issued a script containing four sentences, none of which contain information. A man in a wedding suit is explaining to her that the wedding is his. A woman with three children under six is being told that the hotel voucher system is experiencing high volume. Somewhere a screen updates DELAYED to DELAYED, which is a design achievement nobody has yet been fired for.
Around 1am the tone changes. It is not really a decision anyone makes. A phone gets thrown. Somebody climbs onto the counter to address the crowd, as if the crowd were the problem. A bank of chairs goes over. Four hundred adults who have been standing in a line for nine hours discover that the line was the only thing holding them.
And then the police — who, unlike the airline, are never understaffed. They arrive fast, in numbers, kitted out, radios working, systems online, budget intact. They have no flights either. What they have is authority.
Pepper spray, marinate, simmer down.
⸻
It deserves the culinary vocabulary it has earned, because that is precisely the procedure. The crowd is not dispersed; one angry passenger is arrested and made an example of— and then the room is left to rest. Coughing counts as agitation. By 3am it has simmered down to a low, even sorrow that requires no further attention from management, which was always the desired doneness.
Note the division of labor. The country could not find enough people to safely direct airplanes. It found thirty of them in eleven minutes to help the passengers simmer down. This is not incompetence — incompetence is random, and this is not random. This is a budget. Somebody sat in a room and decided which of those two capacities the republic would keep funded, and they were not confused about it, and they were correct about what they would need.
Terminal Braise
Serves 400. Total time: 9 hours, plus resting.
400 travelers
Room temperature. Do not let them settle; bolt the seating so it cannot be reclined.
1 cancelled flight
Announced at 2am, off-menu, no substitutions.
4 gate agents
Deboned of all information. Keep visible — they absorb the heat.
Fluorescent light
Full, continuous, no dimmer. Prevents the mixture from setting.
1 outlet per 40 guests
For tension. Encourages the crowd to season itself.
Capsaicin, to taste
Applied as a fine mist, evenly, without regard to which portions were already tender.
Method
Delay. Reduce. Agitate. Season generously. Rest until quiet. Serve at 6am to a connecting flight that has also been cancelled.
X
A Modest Proposal, Aviation Edition
I wondered aloud in the chat what would happen if healthcare workers used this strategy.
The answer, I think, is nothing. Nothing visible. That is precisely the problem, and it is the difference between the two collapses.
When aviation fails, it fails all at once and in public. Eight airports go dark on a map. Cancellations aggregate into a number a news desk can put in a headline. A cabinet secretary must appear on a Sunday program and say a sentence. The failure has a shape, a location, and a spokesman.
When healthcare fails, it fails one person at a time, in private, at a pace slow enough to be mistaken for normal life. Nobody issues a ground stop. There is no board of red CANCELLED beside every name. There is a voicemail about prior authorization. There is a first available appointment in March. There is the 6th bill that arrives twelve months later, itemized in a language invented specifically so that it cannot be disputed. There is a man in a parking lot rationing an injection because the alternative is his daughter’s tuition.
The Bulbul has practiced medicine for decades. He has never once been able to call in sick in a way the country would feel. Nobody would ground a single flight. The delay would simply be distributed — to a waiting room, to a hallway bed, to a phone tree, to the exhausted — which is where it has been distributed the entire time.
The system does not lack a plan. Distributing the failure onto individuals is the plan.
⸻
XI
The DIY Healthcare Kit
So the market has done what markets do when a public good stops arriving. It has packaged the absence and sold it back, at retail, with free shipping over $35.
What follows is the standard household kit as currently assembled by roughly everyone I know. Contents may vary by state, by employer, and by whether your father is a physician.
Contents of the Kit
One (1) laminated card
Reads: HAVE YOU TRIED DRINKING WATER AND GETTING MORE SLEEP. Doubles as an ice scraper.
Search engine, unlimited
For self-diagnosis. Every symptom resolves to either dehydration or something with a five-year survival rate. There is no third result.
Chatbot triage, free tier
Twenty messages a day. Endlessly patient, faintly hedging, available at 3am — which is more than can be said for the on-call line, and it does not bill you.
Veterinary-grade supplies
Sutures, saline, antibiotics labeled FOR AQUARIUM USE ONLY. The fish are, notably, not asked for a copay.
Prior authorization dice
Roll for coverage. On a 1, the medication your physician selected is denied by someone who has not attended medical school and will not be identified.
A friend who is a nurse
Not included. Must be sourced independently. Answers texts at all hours, unpaid, and is the actual load-bearing element of this kit.
One (1) GoFundMe template
Pre-filled. Optimized for the photograph in which you still look well. A stranger’s pity, priced at a 2.9% processing fee, is now a recognized payer.
Insulin, one vial
Financed over thirty-six months. Also available same-day, six hours south, in a country the kit does not name.
Blood pressure cuff, imported
Ships from Shenzhen in nine days. The one in the clinic came from the same warehouse. Yours cost less.
A physician father, if available
The Bulbul model. Diagnoses by WhatsApp, opinions unlimited, second opinions free, has never billed a member of his own family or, judging by his lifestyle, most of yours.
Meal voucher, $15
Valid only at a terminal restaurant that closed in 2019. Included for continuity with the aviation module.
This kit is not a substitute for medical care. Neither, increasingly, is medical care. Some assembly required; all assembly required; you are the assembly.
XII
Coda, Gate B33
So: a family stranded overnight by an air traffic system that has run out of people, in a country that will hire them in two years, in an airport whose staff were forbidden the dignity of an explanation and whose only fully funded service arrived at 1am with a canister. A woman crying with relief because a plane exists. A woman eating potato chips who has calibrated hardship against an actual war and finds this an almost imperceptible inconvenience. Both of them are right. That is the strangest part.
You can be a captive of a failing system and still be the luckiest person in the terminal. Both things run on the same track. Empire ends the way our flight ended — not with a bang, but with a gate agent who does not have the information, and a crowd that has learned not to ask twice.
And still: to the Midwest. Where I am free to try, and to fail, and to keep trying — which, when the machinery stops, is the entire remaining infrastructure, and which is why we came for the piece of paper in the first place.
Written from a ranch in the hills of Mendocino County, where the sun comes close enough to touch and 140 acres of solitude echo the sounds of success
There is a particular kind of object that fools you.
It looks simple. A colored block. A flat plastic tile. You look at it and think: a child could have designed this. And that thought — that specific, seductive thought — is the trap. Because the simplest-looking objects tend to have the most complicated histories, and the gap between who invented a thing, who owns a thing, and who got rich from a thing is where fortunes are made, lost, litigated, and quietly stolen.
I want to tell you about two toys.
Both are in your house right now, or were, or will be. Both are considered iconic examples of their country of origin. Both are wrong about that. And both of them ended in a courtroom teaching the same lesson from opposite directions.
Neither story ends where you think it does.
PART ONE: THE DANISH BRICK THAT WASN’T DANISH
I. The Fairy Tale
Everyone knows the Lego origin story, because Lego tells it very well.
A Danish carpenter named Ole Kirk Christiansen, in the town of Billund, starts making wooden toys during the Depression. He names the company from the Danish leg godt — “play well.” His son takes over. The family perseveres. The bricks conquer the world. Four generations later it’s still family-owned, the largest toy company on earth, and a genuine cultural institution.
Every word of that is true.
It is also missing the part where the brick came from somewhere else.
II. Hilary Fisher Page
The man you’ve never heard of is named Hilary Fisher Page, and he deserves better than he got.
Born in Sanderstead, England on 20 August 1904, the first child of a father who worked in the lumber trade, Page made his own wooden toys as a child and was educated at Shrewsbury School from 1918 to 1923. He was, by every account, a serious man about a serious subject. A biographer records that he spent the whole of every Wednesday in a different nursery school, sitting on the floor and playing with the children, to find out exactly what kind of toys would interest them most.
That detail matters. Page wasn’t a manufacturer looking for a product. He was a child-development obsessive looking for a better toy. He had become increasingly unhappy using wood as a material for children’s toys and was an early advocate of plastics as a safe and hygienic alternative. In 1936 he began manufacturing Kiddicraft “Sensible” toys using new injection moulding technology. This is what motivated him to make toys from plastic rather than wood — they were safer and cleaner for children to play with.
Then he invented the thing.
In April 1939, Page applied for British patent #529,580, “Improvements in Toy Building Blocks,” which was accepted in November 1940. It described hollow square bricks with four studs on top. The bricks were hollow rectangular plastic bricks with four round studs on top; the sides of the blocks could fit between the studs of another block, allowing children to build up structures such as walls.
Read that description again. That is a Lego brick. In 1939. In England. Patented.
Page kept going. He patented the basic 2 × 4 studded brick design in 1947, followed by patents for the side slits in 1949 and the baseplate in 1952 — designs now featured in exhibits at the Brighton Toy and Model Museum. The Kiddicraft Self-Locking Building Brick sets were first marketed in 1947, and as a promotion Page and his family built large display models for the 1947 Earl’s Court Toy Fair. His daughter Jill remembered building “Sky Scrapers” that were as tall as she was — five foot six.
There is a photograph in my head of that scene that I cannot shake: a man and his daughter, at a toy fair in postwar London, building a plastic skyscraper taller than she is, out of a brick he invented, for a company that will be a footnote within a decade.
III. The Copy
Here is how it happened, and the mundanity of it is the point.
Kirk Christiansen, the founder of Lego, came across these bricks in a demonstration he was shown of an injection moulding machine. He then copied the bricks and sold them under his own brand as “Automatic Binding Bricks.”
Not corporate espionage. Not a stolen blueprint. A sales demo for a plastics machine. The machine vendor needed something to mould to show what the machine could do, and what they had lying around was a Kiddicraft brick.
Ole and Godtfred would copy both the Interlocking Building Cube (as Lego Plastic Byggeklodser) and the Self-Locking Building Brick (as the Automatic Binding Brick).
Was it illegal? Here the story gets genuinely murky, and I want to be fair to the Danes. One argument holds that Lego technically stole nothing, since in Scandinavian countries the Self-Locking Building Bricks were never patented — a patent is a national instrument, and a British patent does not restrain a Danish manufacturer. It has also been noted that the Self-Locking Building Bricks were just one of a bunch of products created by Page, and one of the less successful ones, with poor sales — British kids preferred the more versatile Minibrix.
So: a commercially struggling product, unprotected in Denmark, copied by a man who saw more in it than its inventor’s market did.
That’s not theft. That’s something more uncomfortable. That’s the ordinary operation of the patent system, working exactly as designed, producing a result that feels wrong.
And this is the part that should make every inventor’s stomach turn over:
Page died without ever finding out that Lego had copied his product.
He died on 24 June 1957, aged 52. He never knew. The most successful toy in human history was being manufactured in Denmark from his design, and the man who spent his Wednesdays sitting on nursery floors went to his grave without the information.
IV. What Lego Actually Invented
I don’t want to be unfair to Godtfred Kirk Christiansen, because he did invent something, and it was the thing that mattered.
Page’s bricks had a flaw. The problem Page faced with early plastics production was tolerance and grip. In order to grip well — a property now called “clutch power” — the space a brick’s stud fitted into had to be deliberately fractionally too small, so the walls of the receiving brick had to flex to accommodate the stud. That flexing meant the receiving brick’s walls were effectively “sprung” to grip the stud. If the space is a perfect fit for the stud, or fractionally larger, the brick doesn’t hold.
Page’s bricks didn’t hold well enough. Kids’ towers fell down.
After Lego adopted the same style of bricks as Kiddicraft, they made many improvements, such as adding tubes inside the bricks to make them stick together. That is the stud-and-tube coupling: the hollow tubes on the underside that grip the studs from within. It solved the tolerance problem, and it is the reason a brick manufactured in 1958 still clicks satisfyingly into one manufactured this morning.
Godtfred filed for it in January 1958.
So the honest accounting is this: Page invented the brick. Lego invented the grip. One of those men is a footnote and the other founded a dynasty, and the difference between them is not the quality of the idea.
V. The Purchase
Some 31 years later, Lego acquired Kiddicraft — while they were preparing to, ironically enough, sue Tyco for illegally copying their bricks.
Sit with the choreography of that. Lego is about to go to court to stop a competitor from copying its brick. Its lawyers, doing diligence, look at the chain of title on the brick itself. And someone in a conference room in Billund says: we should probably own Kiddicraft before we walk into that courtroom.
They bought the ghost so it couldn’t testify.
PART TWO: WHAT HAPPENED IN COURT
This is the part of the Lego story nobody tells, and it’s the part that actually matters if you own a patent.
I. Interlego v. Tyco (1988)
Tyco Industries and its Hong Kong subsidiary entered the model-building market in 1983, producing bricks compatible with Lego by reverse engineering Lego products. Lego sued Tyco in Hong Kong for copyright infringement of the design drawings used to manufacture Lego and Duplo bricks.
Note the theory carefully, because it’s clever and it’s desperate. Lego did not sue over the brick. Lego sued alleging infringement of copyright in its engineering drawings — not the bricks themselves.
Why? Because the patents were gone. Lego’s rights were originally based on designs by Hilary Page, whose patents expired in the 1950s; Lego’s own improvements, including the third-generation brick with enhanced clutch-power, were protected by patents and registered designs until 1975.
Patents expire. Copyright, in 1988, lasted the author’s life plus fifty years. So if you could argue that your engineering drawings were protected artistic works, and that anyone making a compatible brick had indirectly copied those drawings — you could resurrect a dead monopoly and give it another century of life.
Lego also argued that its post-1972 drawings, which largely copied the earlier drawings with minor technical amendments, qualified as original artistic works entitled to a fresh term of copyright.
Redraw the drawing, restart the clock. Forever.
On 5 May 1988, the Judicial Committee of the Privy Council — Lord Keith of Kinkel, Lord Templeman, Lord Ackner, Lord Oliver of Aylmerton and Lord Jauncey of Tullichettle — decided the case.
The Privy Council dismissed Lego’s appeal and allowed Tyco’s cross-appeal, with the result that Lego’s claim of artistic copyright infringement was dismissed except with regard to two minor items. No copyright subsisted in Lego’s pre-1973 drawings, and the post-1972 drawings did not qualify as original artistic works entitled to copyright. Consequently, Tyco’s manufacture of compatible bricks did not infringe Lego’s copyright except in limited cases. Lego’s attempt to extend its monopoly beyond patent and design protections through copyright claims on minor drawing modifications was rejected.
The court’s reasoning is worth quoting in substance: after Lego’s patent and design protection expired, it claimed copyright protection in drawings of the blocks which included a number of minor variations from the original block design, and the Privy Council dismissed the claim that the revised drawings constituted an artistic work.
Lego lost. Tyco was allowed to continue selling the bricks, which at the time were earning them about $20 million annually.
II. Kirkbi v. Ritvik (2005)
Seventeen years later, in Canada, Lego tried the other door.
Kirkbi AG owned patents for Lego toy building blocks, the last of which expired in Canada in 1988. After the patents expired, Mega Bloks began marketing a line of blocks identical in size to Lego blocks, using the same geometrical pattern of studs on top coupled with tubes underneath.
The plaintiffs commenced a passing-off action under s. 7(b) of the Trade-marks Act, asserting unregistered trademark rights with respect to the “Lego indicia” — the distinctive geometrical pattern of raised studs on the upper surface of the block.
The theory: even if we can’t patent the studs anymore, the studs are so recognizably ours that they function as a brand. A trademark. And trademarks, unlike patents, never expire as long as you keep using them.
The Registrar of Trade-marks refused registration, so Kirkbi claimed the Lego indicia as an unregistered mark and relied on s. 7(b) and the common law doctrine of passing off.
On 17 November 2005, the Supreme Court of Canada, in unanimous reasons by LeBel J, dismissed the appeal and held that Kirkbi’s passing-off claim was barred by the doctrine of functionality.
The Court held that Kirkbi’s design was purely functional, and that “a purely functional design may not be the basis of a trademark, registered or unregistered.” The Lego indicia trademark was primarily functional and therefore invalid; the plaintiffs were attempting to extend their expired patent protection through the guise of a trademark, which was contrary to the policy underlying trademark law.
The ruling had a profound effect on the toy industry, enabling competitors to produce compatible building-block products without fear of trademark infringement claims based on functional shapes, and directly facilitating the market entry and expansion of rivals like Mega Bloks in Canada. It also reverberated internationally, informing Lego’s ongoing litigation against Mega Bloks in the European Union and the United States, where courts after 2005 drew on Kirkbi’s logic.
Two courts, two continents, seventeen years apart, same answer:
You get twenty years. You do not get to launder an expired patent into a permanent right by calling it something else.
III. So Why Is Lego Still Winning?
Here is the fact that makes the whole thing click.
Lego lost the copyright case in 1988. Lost the trademark case in 2005. Its patents have been expired for half a century. Anyone on earth may legally manufacture a brick that snaps onto yours.
Lego had revenue of 83.5 billion Danish kroner — about $12.6 billion — in 2025. It is owned 75% by Kirkbi and 25% by the Lego Foundation, and employed 31,282 people as of 2024. Kjeld Kirk Kristiansen and his three children have a combined net worth of nearly $25 billion. Kjeld’s own net worth was approximately $10.2 billion as of November 2025.
The monopoly is gone. The money is bigger than ever.
Because of what the family built while the patent was still alive: Kjeld oversaw the expansion of Legoland theme parks in the 1990s and began the practice of licensing branding rights from moviemakers, which led to the release of Star Wars-themed building sets in 1999. The company also expanded into computer games, films and clothing.
That’s the answer. Mega Bloks can copy the stud. Mega Bloks cannot copy Star Wars. Mega Bloks cannot copy Legoland. Mega Bloks cannot copy the fact that a brick from 1958 fits a brick from today, a compatibility promise maintained across seven decades of manufacturing discipline that no new entrant can retroactively acquire.
The patent bought twenty years of cover. What Lego built under that cover is the actual business — and it turns out that what it built was not protected by the patent at all.
PART THREE: THE JAPANESE TILE WITH THE GREEK NAME
Now the mirror image.
I. Pythagoras
If you have a small child, you have stepped on a Magna-Tile barefoot in the dark and briefly reconsidered your entire life. They’re the translucent magnetic polygons that snap edge-to-edge into glowing little cathedrals. They feel American in a specific way — the earnest, STEM-forward, wooden-Montessori-adjacent educational toy.
They are Japanese.
Magna-Tiles were originally developed in Japan, where they were sold under the name Pythagoras. Magna-Tiles is the U.S. version of an educational toy called Pythagoras, which People Corporation began selling in Japan in 1992. The trademark “Pythagoras” (ピタゴラス) was applied for in Japan by People Corporation Ltd. on 25 December 1991 and registered on 31 May 1995, Japanese registration number 2707566.
II. The Salesman
American salesman Rudy M. Valenta saw the toy while visiting Japan in 1996 and bought the rights to it. He founded Valtech Co. in 1997 with his wife Noriko, to bring the magnetic tile sets to the US and the world.
And then the single most instructive decision in this entire essay:
At first the product was launched in the US under the name Pythagoras, but it had little traction, as the branding and name did not match the US market. It was quickly rebranded to Magna-Tiles, and carried the Pythagoras logo on the packaging for a few years before it was dropped permanently.
Read that as an IP practitioner and it’s almost too neat. The product was identical. Same tiles, same magnets, same geometry, same everything. The only variable changed was the name, and the name was the difference between a product with little traction and this:
Sales began slowly, but by 2015 Magna-Tiles were being described as “ubiquitous” among young children in the United States, and the New York Times and other publications have highlighted them as a top toy.
Rudy Valenta did not invent the tile. He did not invent the magnet. He did not invent the geometry, the edge-capture mechanism, or the educational theory. He invented a word, and the word was worth more than the invention.
III. What Valtech Actually Enforces
Now watch what they defend in court — because it is not the tile.
In litigation in the Northern District of Illinois, Valtech alleged that defendants were selling transparent, colorful plastic building blocks in various sizes and colors almost identical to Magna-Tiles under the brand names “Magnetic Stick N’ Stack” and “Playmags.” Rudolph Valenta, owner of Valtech, holds a federal registration for the mark “Magna-Tiles” for use in association with toys, blocks and puzzles — U.S. Reg. No. 2,654,320. Valtech also claimed that the packaging used by the defendant was identical, or at least confusingly similar, to the packaging used for Magna-Tiles.
The court’s own summary of the claims describes them as trade-dress violations, with Valtech competing for sales against products that infringe on Magna-Tiles’ trade dress.
Trademark. Trade dress. Packaging. Not the tile. The name and the look.
This is not an accident or a weak litigation strategy. It is the only ground they have, and they know it, because the underlying concept was never theirs to lock up. The magnetic-tile category is now a crowded field — similar products include Magformers, Playmags, CONNETIX and Picasso Tiles — and the patents in the space are held by scattered parties. To pick one at random: U.S. Patent 10,857,475, issued 8 December 2020, covers a magnetic-tile game set with holding strips to prevent buckling, plus accessories like figurines and lighting — a genuine invention, owned by someone who is not Magna-Tiles.
And yet:
Magna-Tiles bills itself as America’s #1 Magnetic Building Sets Brand, operating out of Bolingbrook, Illinois, and in March 2025 revealed its first fan-made invention at the American International Toy Fair.
The MAGNA-TILES trademark is now held by MVW Holdings, Inc., filed 22 April 2018, covering toy building blocks, toy construction blocks, and construction toys incorporating magnets.
No foundational patent. Number one anyway.
PART FOUR: THE LESSONS, STATED PLAINLY
I’ve been on both sides of this. I have been the man with the clever mechanism and the pending application, convinced the mechanism was the thing. And I have watched, more times than I care to count, the money flow past the cleverest mechanism to whoever controlled the system, the name, and the factory.
Here is what these two toys, laid side by side, actually teach.
1. A patent is a candle, not a sun.
Twenty years, and then it is gone, and your competitors are legally entitled to everything you disclosed. That is not a bug — the disclosure is the deal. You told the public how it works; in exchange you got two decades of exclusivity. When the term ends, the public collects.
The Privy Council said no in 1988. The Supreme Court of Canada said no in 2005. Lego, one of the best-resourced litigants in the toy industry, tried to extend an expired monopoly through copyright and then through trademark, and lost both times, because courts are specifically alert to that maneuver.
Plan for the expiry from the day you file. If your business dies when the patent does, you don’t have a business. You have a countdown.
2. The winner is whoever owns the commercial rights and the story — not the inventor.
Hilary Fisher Page invented the interlocking brick and died not knowing it had conquered the world. A Japanese math-toy company invented the magnetic tile and is invisible in the American market it created. The Christiansens and the Valentas won.
This is not a morality tale about theft. Lego improved the brick meaningfully. Valenta took real risk importing an unproven product. But neither of them originated the core idea, and both of them captured essentially all of the value, and if you are an inventor you need to internalize why: they controlled distribution, brand, and manufacturing. Those are not lesser assets than invention. In the long run they are the only assets.
3. In the “deceptively simple” category, provenance is the whole game.
Both of these products live in the most dangerous neighborhood in IP: ideas that look too obvious to own. Construction systems. Snapping parts. Elementary geometry.
That is precisely the category where an earlier, obscure, foreign design surfaces at the worst possible moment. Lego’s origin has a permanent asterisk on it for exactly this reason — even the Privy Council’s own recitation of the facts begins by noting that Lego’s rights were originally based on designs by Hilary Page. Forty years after the fact, the ghost was still in the record.
If you are filing in a simple-mechanism space, prior-art search is not a formality you delegate and forget. It is the load-bearing wall.
4. Build a “tell.”
Lego has clutch power. Magna-Tiles has its lattice and its name.
The tell does double duty. It is functional, and it is a signature — an instantly legible marker that says this is the real one. Note carefully, though, what Kirkbi teaches about the limits: a purely functional design may not be the basis of a trademark, registered or unregistered. A tell that is nothing but function will not survive as trade dress. It needs an arbitrary, aesthetic, non-necessary component — something you chose when you didn’t have to.
That non-necessary flourish, the part an engineer would call waste, is the part that can outlive your patent by a century.
5. Name it before you perfect it.
The Pythagoras-to-Magna-Tiles rebrand is the cheapest, highest-return act in either story. Zero engineering. Zero tooling. A word.
Inventors systematically underweight this because naming feels like marketing, and marketing feels like the thing you do after the real work. It isn’t. It is the asset with the longest half-life you will ever create. The tile is copyable. The mould is reverse-engineerable. The patent expires on schedule.
The name is forever, if you feed it.
CODA
The candle burns for twenty years. It is bright, and it is genuinely useful, and it makes you feel like you own something permanent.
You don’t. You own time. That’s all a patent has ever been: a fixed quantity of protected time, purchased with public disclosure.
What you do inside that window — the brand you build, the factory tolerances you dial in, the promise you make to customers and then keep for seventy years, the word you put on the box — that’s the part nobody can take when the candle goes out.
Hilary Fisher Page had the better claim and died anonymous. Rudy Valenta had no claim at all and built an empire on a rebrand.
The difference wasn’t the invention.
Out here on the ranch, where the silence is complete enough to hear your own thinking, that’s the thought that keeps circling back. The simplest brick. The hardest lesson.
SOURCES
Kiddicraft & Hilary Fisher Page – Wikipedia, “Hilary Page” — biography, dates, Kiddicraft founding, plastics advocacy – hilarypagetoys.com, “K281 Kiddicraft Interlocking Building Cubes” — British patent #529,580, applied April 1939, accepted November 1940 – Brickipedia, “Kiddicraft” — 1940 patent, brick geometry, Lego’s tube improvement – Shameless But Famous Wiki, “Kiddicraft Blocks” — 1947 basic-brick patent, 1949 side slits, 1952 baseplate, Earl’s Court Toy Fair – Brickfetish.com, “1947 — Kiddicraft” — Page’s nursery-school research, Jill Page’s recollection, Lego’s copying of both product lines – Brighton Toy and Model Museum — clutch-power tolerance problem, Page patent images (GB587206, GB633055, GB673857) – atlbrick.com — Cellulose Acetate composition, 1945 slot improvement, plastics rationale – TodayIFoundOut.com — injection-moulding demo origin, Scandinavian non-registration, Kiddicraft acquisition, Page’s death without knowledge
Interlego A.G. v. Tyco Industries Inc. [1989] AC 217; [1988] UKPC 3 – Wikipedia, “Interlego AG v Tyco Industries Inc” — 5 May 1988, panel composition, full citations – CaseMine — full holding, Page patent lineage, Tyco reverse engineering from 1983, pre/post-1973 drawings – vLex Canada — appeal dismissed, cross-appeal allowed, artistic-work analysis – CaseMine commentary — Seventh Schedule analysis, functional vs. aesthetic boundary – lawprof.co — Paragraph 8(2), Schedule 7, Copyright Act 1956
Kirkbi AG v. Ritvik Holdings Inc., 2005 SCC 65, [2005] 3 SCR 302 – Wikipedia, “Kirkbi AG v Ritvik Holdings Inc” — 17 November 2005, LeBel J unanimous, doctrine of functionality – Supreme Court of Canada, decisions.scc-csc.ca — official reported decision – vLex Canada — Canadian patent expiry 1988, Lego indicia claim, extension-of-monopoly reasoning – Smart & Biggar, “LEGO Loses Trademark Battle in Canada” — the “purely functional design” holding – DWW, “A Leading IP Case: Lego® and Mega Bloks®” — constitutional and functionality holdings – Grokipedia — downstream effect on Mega Bloks market entry and international litigation
Magna-Tiles / Pythagoras / Valtech – Wikipedia, “Magna-Tiles” — Japanese origin, Valenta 1996 discovery, Valtech 1997 founding, rebrand, 2015 ubiquity, competitor list – Hattori & Partners (Japanese patent attorneys), “MAGNA-TILES” — People Corporation 1992 sales, Pythagoras trademark JP Reg. 2707566, filed 25 Dec 1991, registered 31 May 1995 – Valtech, LLC v. 18th Ave. Toys Ltd., 14 C 134 (N.D. Ill. Feb. 12, 2015) — trade dress claims, U.S. Reg. No. 2,654,320, packaging allegations – govinfo.gov, official court PDF of the above – Justia Trademarks — MAGNA-TILES held by MVW Holdings, Inc., filed 22 April 2018 – U.S. Patent 10,857,475 (Justia) — third-party magnetic-tile patent, issued 8 Dec 2020 – ZoomInfo / PRNewswire releases — Bolingbrook IL, “America’s #1” positioning, March 2025 Toy Fair
Lego Group financials & ownership – Wikipedia, “The Lego Group” — 2024 revenue 74.3bn DKK, ownership split, headcount – Wikipedia, “Kirkbi” — holding structure, subsidiaries, 2023 generational transfer – Bloomberg Billionaires Index (Kjeld Kirk Kristiansen; Sofie Kirk Kristiansen) — 2025 revenue 83.5bn DKK / $12.6bn, 75% Kirkbi stake – Forbes profile, Kjeld Kirk Kristiansen — ownership split, succession – Fortune / Yahoo Finance — combined family net worth ~$25bn, Kirkbi net income – Grokipedia — $10.2bn net worth as of November 2025
A NOTE FROM THE AUTHOR
I want to be careful about the moral framing here, because it would be easy to write this as a heist story and it isn’t one.
Ole Kirk Christiansen did not steal Hilary Page’s brick in any sense a court would recognize. He saw an unprotected foreign product at a machine demo, recognized something in it that its own inventor’s market had not, and then spent years fixing the engineering flaw that had kept it from working properly. That is what innovation frequently looks like from the inside — not a lightning bolt, but somebody noticing an underperforming thing and being unreasonably stubborn about improving it.
Rudy Valenta didn’t steal anything either. He bought the rights, legitimately, and took the risk of importing a toy that had already flopped once under its original name.
The discomfort in both stories isn’t villainy. It’s the system working correctly and producing an outcome that feels unjust anyway. Page’s protection didn’t extend to Denmark, because patents are national. The Japanese inventors sold their commercial rights, because that’s what rights are for. Nobody broke a rule.
And yet one man died not knowing, and another man’s fortune is measured in the billions.
If there’s a reason to keep telling these stories, it’s this: inventors are systematically miscalibrated about which asset matters. We overvalue the mechanism and undervalue everything downstream of it — the name, the factory, the promise, the decades of boring consistency. We treat the patent as the prize when it is merely the starting gun.
I write this from a place where you can see a long way in every direction, which turns out to be a useful condition for thinking about time horizons. Twenty years is not very long. Ask anyone who’s watched a patent expire.
— Oskar Rausch, Mendocino County, California
Nothing in this essay is legal advice. If you have a pending application in a crowded mechanical art, retain a competent patent attorney and pay them properly. The one thing every story in this piece has in common is that the cost of good counsel is trivial compared to the cost of finding out late.
