Posted on by omarmetwally

The Flexible Way

By Omar Nabil Metwally, M.D.

Years ago, in a bookshop in Vietnam, I picked up a paperback with a cover I have never managed to forget: Vladimir Putin in a white judogi, mid-throw, with the settled calm of a man who knows exactly where his partner is about to land. I filed it in my memory as an old book, something from the 1970s, from his years as a working intelligence officer. Then I put it back on the shelf and walked out, and for years the cover did what unread books do, which is to become more interesting in the memory than it ever was on the page.

This week a German radio documentary about a Japanese schoolteacher pulled that cover back off the shelf. And because I am a jiu-jitsu practitioner who is, at the moment, spending more time on the couch than on the mat, I had the time to find out what I had actually seen.

The correction first. The book cannot have been from the 1970s. In 1976 the Leningrad Evening News ran a small item noting that a previously unknown local judoka had won a city championship and that readers might hear more of him. Nobody prints book covers of unknown lieutenants. What I saw was almost certainly a Vietnamese edition of something from the 2000s, when a sitting head of state did the unusual thing of co-authoring a judo manual. Memory, it turns out, performs its own kuzushi. It gets you off balance first and lets you fall under your own weight.

The empty chair

The documentary is Wie Kano Jigoro den Kampfsport Judo erfand (“How Kano Jigoro invented the combat sport of judo”), written by Jenny von Sperber for Bayerischer Rundfunk’s Radiowissen series and broadcast on October 28, 2026. Everything I know about Kano that I did not know last week comes from it and from the three experts she interviewed: Wolfgang Dax-Romswinkel, a sports historian and kata world champion; Maja Sori-Doval, a sports scientist at Tsuda University in Tokyo; and Hans Joachim Teichler, a historian of sport under the Third Reich. I am translating freely and the mistakes are mine.

It opens in the Kodokan in Tokyo, the oldest judo school in the world, where children between six and nine train six days a week on a sprung floor of 420 tatami mats. On the wall hangs a black-and-white portrait of Kano: black jacket, white moustache, unreadable gaze. In front of the portrait, on a small raised platform, stands his chair. It is empty. He died in 1938. At the end of practice the children bow, one after another, to the chair and the photograph, and then wander off chattering to their bags at the edge of the mat.

I have been thinking about that chair all week. Every academy I have ever trained in has one, whether or not anyone has bothered to build it.

A small boy who got picked on

Kano was born in Kobe in 1860, the third son of a sake brewer and shipping man, in the decade when the samurai class was being abolished and money began to matter more than birth. He had the best education that money could buy: Chinese, English and German in school, then literature, politics and economics at university in Tokyo. He rowed, ran, hiked, and was among the first people in Japan to play baseball. He was also, by his own account, a small and scrawny boy who got picked on, which is why he went looking for a jujutsu teacher at a time when the old warrior arts were considered embarrassing relics and the whole country was looking outward.

Here is where von Sperber’s piece earned my trust. Dax-Romswinkel lets the legends breathe and then lets a little air out of them. There were hundreds of jujutsu schools, each hoarding its secret techniques and fighting the others for survival. Kano’s teachers kept dying or going broke. So, having money, he rented a room in 1882 and founded his own system. At first it was regarded as just one more school, Kodokan Jujutsu. But Kano, Sori-Doval says, was not really founding a school. He was designing a curriculum for a modern nation, and that is why it worked. He may not have been the strongest fighter, but he had the best concept.

And the famous police tournament, in which the Tokyo police supposedly pitted Kano’s students against the older schools, the Kodokan swept the field, and judo became the official system of law enforcement and the army? Dax-Romswinkel notes that the Kodokan fighters were in their mid-twenties, doing what he calls high-speed attacking judo, while the representatives of the other schools were considerably older. This is the most honest sentence about martial arts I have heard in years, and every white belt who has ever been crushed by a fifty-year-old purple belt will understand why.

What he took out, and what he put in

If you train jiu-jitsu, pay attention to this part, because it is your own origin story told from the other side.

Kano did not invent new techniques. He took techniques that already existed and put them in a new structure, and the most important thing he did was subtraction. Out went finger locks and wrist locks. Out went striking, which the jujutsu schools had kept for self-defense. The only joint you were allowed to attack was the elbow. Sori-Doval’s point is that this subtraction was the whole invention: it produced an art you could practice at full intensity, against a resisting partner, without maiming him. That meant it could be taught to schoolchildren, to police, to soldiers and, from the very beginning, to women, which was not obvious in 1880s Japan.

Then he named it. Ju means yielding or flexible; do means way, or system, or principle. Not “the gentle art.” The flexible way. And he gave it two principles that he spent the rest of his life refining: seiryoku zen’yo, use your energy, physical and mental, to maximum effect; and jita kyoei, mutual welfare, which Dax-Romswinkel renders as “I and others flourish together.” It is not enough, Kano said, to do judo. Whatever a judoka does, in society, must be something useful.

Judo, in other words, was never a sport with a philosophy attached. It was a philosophy of education that happened to use throws. In Japan today Kano is remembered less as the founder of a martial art than as a reform educator and university president who ran the nation’s teacher training for twenty years, complained constantly that schools fed the intellect and starved the body and the character, and became, in 1909, the first Asian member of the International Olympic Committee. He believed that intellectual, physical and moral education deserved equal rank. I have spent a career in medicine watching what happens to people who got only the first one.

The flexible way goes to Brazil

Sori-Doval mentions, almost in passing, that the first Kodokan teacher went abroad in 1903, to America, and ended up teaching the president. That was Yoshitsugu Yamashita, and the president was Theodore Roosevelt. Kano’s recipe for spreading judo, she says, was to send teachers overseas and to let them adapt to the place they landed. Judo in Germany or Brazil today is not the same as judo in Japan, and that was the point.

The Brazilian branch of that experiment is the one I trained in. In 1904 Kano sent a young Kodokan fighter named Mitsuyo Maeda abroad with his senior, Tsunejiro Tomita. Maeda spent the next decade taking challenge matches across the United States, Europe, Cuba and Mexico, where he acquired the stage name Conde Koma, and where his judo, by every account, hardened into something more pragmatic than the Tokyo curriculum. He reached Brazil in November 1914 and settled in Belém, on the mouth of the Amazon. There, around 1917, a teenager named Carlos Gracie watched him demonstrate at the Theatro da Paz, and his father Gastão, a local businessman who had helped Maeda get established, arranged lessons. Newspapers of the day called what Maeda did “jiu-jitsu” no matter how often he said “judo,” and the name stuck.

Everything else you know follows from that: Carlos teaching his brothers, the smallest of them, Hélio, by the family’s account re-engineering the ground game around leverage because his size left him no choice, and a lineage that now runs through academies in every strip mall in America. I find it moving that the art I practice is, technically, a cutting from Kano’s tree that was carried by ship to the Amazon and grafted onto a different rootstock. Different fruit. Same tree. When I bow onto the mat I am bowing, whether I know it or not, to a chair in Tokyo.

Berlin, 1936

Von Sperber does not look away from the uncomfortable part, and neither should I. Kano wanted the Olympics in Tokyo, and in 1936 he got them awarded for 1940. He gave a speech at the Berlin Games, in German, about peoples understanding each other better, and in it he praised the strong will and solicitude of the Führer and Reich Chancellor. Teichler describes how carefully the regime had dialed itself down for those two weeks: the antisemitic display cases cleared from the streets, party members asked to show up in civilian clothes, radio stations told to go easy on the march music, Berliners instructed to be polite.

Was Kano a fascist? Dax-Romswinkel’s answer is careful and, I think, correct: no, but he dealt with fascists, and he moved in a political environment that unquestionably was one. His diaries, written in English, are still locked in the Kodokan; a handful of hand-picked researchers have ever seen them. The 1940 Games never happened. Tokyo finally hosted in 1964, and as a gift to the hosts, judo entered the Olympic program.

That date is where the story turns toward Leningrad.

The Russian who learned from Kano

The thread connecting Kano’s chair to the book in that Vietnamese shop runs through a man most people have never heard of. Vasily Oshchepkov was born on Sakhalin in 1892, the son of a convict, orphaned young, and educated at a Russian Orthodox seminary in Japan. He was good enough at judo that the seminary sent him to the Kodokan, where he was admitted in 1911 and earned his black belt in June 1913, under Kano himself: the first Russian ever to do so and one of the first foreigners of any kind. He went home, worked as a translator in military counterintelligence, taught judo to police in Vladivostok, and in Moscow in the late 1920s began assembling the self-defense system for the Red Army that became sambo.

In October 1937, during the Great Purge, Oshchepkov was arrested as a Japanese spy and died ten days later in Butyrka prison. He was rehabilitated in 1957. For decades afterward judo itself was officially banned in the Soviet Union as an imperialist sport; sambo, its home-grown cousin, was fine. The ban was lifted only when judo was added to the 1964 Olympic program and Soviet sports authorities, wanting medals, lifted the ban. Soviet judoka took four bronzes in Tokyo.

So in the early 1960s, a small boy in a Leningrad communal apartment who wanted to stop being pushed around would be steered into sambo first, and into judo only afterward.

A lightweight from Leningrad

Vladimir Vladimirovich Putin was born in October 1952 and joined the Trud sports club, today called Turbostroitel, at around the age of eleven; some accounts say thirteen, and accounts, as they do, disagree. His coach for the next fifteen years was Anatoly Rakhlin, who started him in sambo and moved him to judo. Rakhlin, interviewed years later by Maureen Orth, described his pupil’s parents as poor and working-class and the pupil as small, light, and willing to fight teammates twice his size. Mr. Putin competed as a lightweight, in the 135-pound class.

The verifiable record, which is what this essay is about, looks like this. He earned the Soviet title of Master of Sports in sambo in 1973 and in judo in 1975. In 1976 he won the Leningrad judo championship, which produced that small newspaper notice. The club’s own fiftieth-anniversary history, deposited in Russia’s Presidential Library in 2019, credits him with 26 or 27 medals, 13 or 14 of them gold, depending on which page you read. Rakhlin, who also did film work, reportedly got him stunt jobs at the Lenfilm studio in the 1970s. He stayed with his coach through university and into his early years in the KGB, and when Rakhlin died in 2013, President Putin, who had decorated him on his 75th birthday a few months earlier, attended the funeral and was photographed afterward walking alone, which is a thing anyone who has lost a coach will understand.

In 2001 he told NPR that judo was, in a way, a philosophy that taught you to treat your partner with respect. In 2006 he told reporters that judo’s slogan, harmony with the world around you and with yourself, was a principle for Russian policy. In 2004 Yasuhiro Yamashita, the Olympic champion, recounted hearing him describe himself as a boy from the Leningrad courtyards who went looking for a way to be tougher and found, instead, “the way.” Whatever one makes of any of that, they are recognizably Kano-shaped things to say. Kano also believed judo would bring world peace, and he meant it.

The book, found

In 2004 Mr. Putin co-authored, with his longtime training partner Vasily Shestakov and Alexey Levitsky, Judo: History, Theory, Practice, published in English by North Atlantic Books with a preface by Keiko Fukuda, who was the last living student of Kano himself. It is a real judo book: the history from jujutsu to the Olympics, the theory of balance, kuzushi, a beginner’s syllabus. Shestakov later had to correct the press for calling him Mr. Putin’s teacher; they only trained together, he said, and besides, he was the younger man. Editions followed in other languages, which is almost certainly the family tree of the paperback I held in Vietnam.

In 2008, for his 56th birthday, came a 75-minute instructional DVD, Let’s Learn Judo with Vladimir Putin. In 2016 a schoolbook, The Art of Judo: From Game to Mastery, with President Putin and his old sparring partner Arkady Rotenberg among its authors, was printed in a run of about seven million copies for Russian primary schools. Kano wanted judo to be school sport for a whole nation. In one country, at least, it became one with the head of state’s name on the cover.

Thrown by a fourth-grader

On September 5, 2000, a few months into his first term, President Putin visited the Kodokan with Prime Minister Yoshiro Mori. Yukimitsu Kano, the founder’s grandson, welcomed him as a fellow member. The president put on a judogi and ran through foot sweeps, shoulder throws and sacrifice techniques with a Kodokan instructor, and then did the thing I keep coming back to: he invited two Japanese children to throw him. Natsumi Gomi, a fourth-grade girl from Tokyo, threw the president of Russia with a seoi-nage; Shu Shikiya, a ninth-grader from Okinawa, did the same. Mr. Putin later invited both children to a tournament in Magnitogorsk to meet Russian kids.

The Kodokan awarded him the sixth dan that day, the rank at which the belt changes from black to red-and-white. According to Yamashita, who hosted him, Mr. Putin declined to put the belt on, saying that as a judoka he understood the weight of a sixth-dan belt and would go home and train until he was worthy of it. He returned to the Kodokan in 2005 and 2016 and said that walking into the building gave him a feeling of peace, like coming home.

Honors then accumulated the way they do around heads of state: honorary president of the International Judo Federation in 2008, an eighth dan from the IJF in 2012, an honorary ninth dan in taekwondo from World Taekwondo in 2013. On February 27, 2022, three days after the invasion of Ukraine, the IJF suspended his status as honorary president and ambassador, and in March removed him and Rotenberg from all positions. World Taekwondo withdrew its ninth dan. Yamashita, the man who had offered him the belt in 2000, said publicly that the actions ran counter to the spirit of judo. The Kodokan did not revoke the sixth dan, explaining that a dan reflects a practitioner’s ability and achievements at the time it is awarded. I set all of this down because it is the record, with no adjectives attached, and readers may weigh it as they see fit. This is an essay about a martial art, not about politics, and I have tried to keep it that way.

For the one on the couch

Now the part I actually wanted to write.

If you are reading this with an ice pack on something, waiting for a surgeon to put you back together, counting the weeks until you can roll again and privately wondering whether you ever will, then this essay is for you, and I have been where you are, or near enough.

The first thing the injury takes is not the sport. It is the identity. For years you were a person who trained, and now you are a person who used to, and the gap between those two people is where all the bad thinking happens at two in the morning. I want to offer you what the schoolteacher in the black jacket would have offered, because I think he would have had a lot to say to you.

He would have pointed out that the thing you miss is not the armbar. Kano’s whole project was to prove that the armbar was never the point. He stripped the dangerous techniques out of jujutsu precisely so that what remained could be a method of education, a way of building a person. Von Sperber’s documentary describes it as a philosophy and not merely a sport, and lists the sheer volume of writing Kano left behind to prove it. The throws were the pedagogy. The person was the product. You are still the product. The factory is temporarily closed for renovation.

Seiryoku zen’yo was never a technique principle alone; Sori-Doval is clear that it means the maximum efficient use of mind and body. Healing is the most efficient use of your energy available to you right now. Doing it with discipline, with sleep and protein and the boring rehab exercises done on the boring schedule, is not a pause in your training. It is your training. The mat will still be there, and you will come back knowing something that the people who never got hurt do not know, which is what the sport is for.

Jita kyoei: you and the other person flourish together. Every injury in grappling is a two-person event, and the ones that happen to good people usually happen because someone, perhaps you, forgot for one second that the person across from you was not an opponent but a partner. When you come back, you will be the one in the room who remembers. That makes you more valuable to your academy than you were before you got hurt. Your sensei knows this. Mine does.

And here is the thing I most want young readers to hear, since so many of the people who find this blog are early in their training and some are early in their lives. Discipline is freedom. I know it sounds like something printed on a gym wall, and it is, but the schoolteacher proved it mathematically more than a century ago. A small, bullied boy in Meiji Japan cannot be free. He is at the mercy of anyone bigger. He had two options: to become bigger, which was not on offer, or to become so disciplined in the use of the body he had that size stopped being the deciding variable. He chose the second, and in doing so he became free in a way that no large boy ever is, because the large boy’s freedom ends the moment he meets someone larger. Kano’s never did. Oshchepkov carried that freedom from Tokyo to Vladivostok; Maeda carried it to the Amazon; a boy in Leningrad found it in a neighborhood sports club; a fourth-grade girl used it to throw a head of state. That is what the belt around your waist means: a record of the days you showed up when you did not feel like it, and the proof that showing up is the one thing nobody can take from you. Not a bigger opponent. Not a torn ligament. Not even a surgeon with a saw, who is, after all, just another partner helping you get back to your feet.

Discipline is what you do when you are injured. Freedom is what you get back when you heal. The flexible way bends. It does not break.

I should also admit that I have been doing the same throw for fifteen years in clinic. You cannot win against a patient’s inertia by force. You wait for the moment they are slightly off balance, usually a Monday, and you lean in with the least energy that will do the job. Kano would have called that seiryoku zen’yo. I call it primary care. Heal well. Bow to the chair.

Sources and further reading

  • Jenny von Sperber, “Wie Kano Jigoro den Kampfsport Judo erfand,” Radiowissen, Bayerischer Rundfunk (Bayern 2), broadcast 28 Oct 2026; editor Yvonne Maier. Interviews with Wolfgang Dax-Romswinkel, Maja Sori-Doval and Prof. Hans Joachim Teichler. Archival audio: Kano’s 1936 Berlin speech (DRA). The primary source for everything here about Kano.
  • Wolfgang Dax-Romswinkel, Kodokan Judo series, Nordrhein-Westfälischer Judo-Verband: nwjv.de. Kodokan Judo Institute: kdkjudo.org
  • Andreas Niehaus, Leben und Werk Kanō Jigorōs (Ergon, 2019); Hans Joachim Teichler, Internationale Sportpolitik im Dritten Reich (Academia, 2022).
  • On Mitsuyo Maeda and the Gracies: Wikipedia, “Mitsuyo Maeda”: en.wikipedia.org; GracieMag, “A brief history of Brazilian jiu-jitsu”: graciemag.com
  • On Vasily Oshchepkov: International Sambo Federation: sambo.sport; Krugosvet encyclopedia (Russian): krugosvet.ru. On the Soviet judo ban: Wikipedia, “Judo at the 1964 Summer Olympics”: en.wikipedia.org
  • TASS, “Putin pays visit to his childhood judo club,” 27 Nov 2019: tass.com; Presidential Library, Judo for Life! Half a Century of Victories (Turbostroitel club history), Dec 2019: prlib.ru
  • Maureen Orth, “Russia’s Dark Master,” Vanity Fair (interview with Anatoly Rakhlin): maureenorth.com; The Moscow Times, “Putin Mourns Judo Coach He Considered Mentor,” 2013: themoscowtimes.com; The Calvert Journal on the Lenfilm stunt work (citing Dozhd): calvertjournal.com
  • RFE/RL, “The Importance of Judo for Vladimir Putin” (NPR 2001 quote): rferl.org; Mail & Guardian, “Putin: Judo ‘harmony’ a principle for Russian policy,” 1 Feb 2006; Joi Ito, “Izu Conference dinner with Yasuhiro Yamashita,” 2004: joi.ito.com
  • Vladimir Putin, Vasily Shestakov, Alexey Levitsky, Judo: History, Theory, Practice (North Atlantic Books / Blue Snake Books, 2004); Mail & Guardian, “Putin deploys new weapon — his judo master,” 23 Jan 2008: mg.co.za; Mother Jones on the 2008 DVD: motherjones.com; Meduza, “7 million copies of Putin’s judo textbook are headed for Russia’s primary schools,” 1 Jul 2016: meduza.io
  • Government of Japan, We Are Tomodachi, Japan and Russia edition 2017 (Yamashita on the 2000 Kodokan visit): japan.go.jp; Kids Web Japan, “Judo” (Natsumi Gomi and Shu Shikiya): web-japan.org; FightingArts.com, “Presidential Judo”: fightingarts.com; TASS, “Putin professes his love for judo and Japanese culture,” 13 Dec 2016: tass.com
  • Reuters via Stars and Stripes, “Putin suspended as honorary president of International Judo Federation,” 27 Feb 2022: stripes.com; Reuters, “Putin removed from all positions on judo’s governing body,” Mar 2022; Around the Rings / Infobae on Yamashita’s 2022 remarks and the Kodokan’s statement on dan ranks, 12 Apr 2022: infobae.com
Posted on by omarmetwally

Hostage Employees and Corporate Malware.

When the software of an organization you work for reaches into a computer you own, and nobody tells you.

By Omar Nabil Metwally, M.D.
Tuesday, October 27, 2026

Originally published at keisenvpa.com on October 27, 2026.

The Last Day

October 23, 2026 was my last day practicing medicine in the United States. I spent part of it at home, at my own laptop, working in the electronic health record of a Corewell Health hospital. Corewell serves Epic to physicians’ own computers through Citrix, a remote-desktop product. Earlier that day, Citrix had asked for permission to inspect the devices on my network. It asked for nothing else.

Afterward, I could no longer take screenshots of my own screen, on my own computer. No one asked for my consent. No one gave notice or sent a memo. KeisenVPA, the documentation tool I build and use, simply told me there were no screenshots. When I called and texted the hospital’s Chief of Medicine, she acknowledged that screen capture had been disabled through Citrix, “just for Epic and Microsoft Outlook.”

The first-hand account, with my own caveats, is in my earlier post: Epic Privacy Violation. And Citrix. This essay is about the pattern that afternoon belongs to.

What Happened, in Plain Words

A remote-access window is supposed to be a window: a computer elsewhere draws a picture on your screen, your keyboard drives it, and the data stays on their side. But the program that draws the window also runs on your computer, with whatever permissions it was given. That makes it a lever. A setting changed on the other side (an employer’s, a hospital’s, a client’s) can change what your own computer may do; in my case, whether it may take a picture of my own screen.

Citrix documents features of exactly this kind. Its App Protection policies include anti-screen capture, under which screenshots and recordings of a protected window come back blank, greyed out or empty, and anti-keylogging, under which, while a protected window is in focus, other software on the computer reads scrambled text instead of your keystrokes (Citrix documentation, last published October 14, 2026; Citrix blog, May 21, 2019). I do not know which setting was used on my laptop. I know what it did.

There is a real reason for such controls: patient information should not leak to screen-scraping malware, and I take that seriously. The tool that came up empty was mine, and an institution may reasonably decide it does not want its record captured on a personal computer at all. My objection, and this is opinion, is not that the control exists. It is that it was switched on, on a computer I own, without telling me, and that nothing on my computer told me either.

“If someone else can change what your computer may do, you should be the first to know, not the last.”

Naming the Pattern

I use two terms for this. They are mine, I use them deliberately, and I define them so they can be argued with.

Corporate malware: software that an employer, hospital, client or vendor places or controls on a device you own, and that acts on that device without your informed consent. The test is not intent; most of this software is written for defensible reasons. It is three conditions together: your device, their control, no informed consent. A control you were told about, understood and agreed to is not corporate malware in my sense. The same control switched on silently is. I am not calling Citrix, or any vendor’s product, malware. Nor am I accusing the hospital, or anyone, of a crime; I am saying that, as I experienced it, the three conditions were present on my laptop that day. The term is about how a control is deployed on someone else’s device and whether they were told, not about the software itself.

Hostage employees: people who must accept software controlled by the organization they work for (as employees, contractors, or physicians with hospital privileges) on a device they own in order to keep working. I use “employees” loosely; in my own story, I held privileges at the hospital. The choice they are offered is to install it or not work. Agreement given on those terms is consent of a sort; it is not much of a choice, and it is not consent to whatever the software is later switched to do. A physician who charts from home. A contractor who must enroll a personal phone to read work email. A remote worker whose laptop is the only computer in the house.

These are opinion and vocabulary, not legal claims. Compliance and legality are different words, and an institution can follow its policy to the letter and still leave the person at the keyboard uninformed. I am not alleging that anyone broke a law. I am saying the arrangement deserves a name. I am a physician, not a lawyer, and nothing here is legal advice. The matter is disputed and pending counsel.

A Trend, Not an Incident

None of this is new, and it is not confined to medicine. A few dated public sources, in order:

  • June 30, 2020. As work moved home during the pandemic, the Electronic Frontier Foundation reviewed employee-monitoring products and called them “bossware.” Every product it looked at could take frequent screenshots of a worker’s device; several recorded keystrokes; many offered remote, “silent” installation on worker computers “without their knowledge”; nine of the ten companies it looked at offered “silent” or “invisible” monitoring, and it named several whose bossware is “designed to be as difficult to detect and remove as possible.” EFF cautioned that its list “may not be representative of the industry as a whole” (EFF).
  • July 29, 2021. The Center for Democracy & Technology published Warning: Bossware May Be Hazardous to Your Health, on monitoring software’s health risks and the gaps in federal protection (CDT).
  • May 7, 2022. New York began requiring private employers that monitor employees’ phone, email or internet use to give prior written notice at hiring and to post it where employees can see it (N.Y. Civil Rights Law § 52-c). Being told is treated as the floor.
  • October 31, 2022. The National Labor Relations Board’s General Counsel issued memo GC 23-02 on “intrusive or abusive” electronic monitoring. It listed keyloggers and screenshot software among the ways employers watch people who work on computers, including at home, and proposed that, where such monitoring is justified by business need, employers disclose to employees the technologies they use, why, and how they use the information (NLRB).
  • February 14, 2025. The NLRB’s Acting General Counsel rescinded GC 23-02, with other memos, in GC 25-05 (NLRB).
  • November 24, 2025. The U.S. Government Accountability Office released a report finding that digital surveillance can both help and harm workers’ health, that heightened stress and anxiety are a concern, and that “these effects can depend on employers’ practices”; it noted that several federal agencies had rescinded or were reviewing earlier guidance in 2025 (GAO-25-107126).

Read together, in my opinion, these describe a ratchet: the tools grow more capable, the remote-access client becomes the one program everyone must install, and the protection for the person at the keyboard depends on where they live and who holds office that year. I expect the ratchet to keep turning.

The boundary already exists: since 2019, Apple has offered a separate enrollment for personally owned devices, where “the user, not the organization, owns the device,” and the organization manages only its own accounts, settings and data (Apple Platform Deployment, page updated September 17, 2026). Whether an employer uses it is the employer’s choice.

Hostage Data

In my opinion, it should be illegal for an EHR company to hold patients’ or physicians’ data hostage. For health records, federal law already goes part of the way. The 21st Century Cures Act prohibits “information blocking,” with civil penalties of up to $1 million per violation for developers of certified health IT and for health information networks and exchanges (42 U.S.C. 300jj-52). Those penalties apply to conduct since September 1, 2023 (88 FR, July 3, 2023). HHS announced a crackdown in September 2025 (HHS), but I have not found a public record of that penalty ever being imposed.

For physicians, the protection is thinner. A practice that owns its records can invoke the same information-blocking rules against its own vendor (45 CFR 171.103). HIPAA also requires the vendor’s contract to make the practice’s patient records available (45 CFR 164.504(e)). A physician as a person has, as far as I can tell, no right of his own. Michigan law makes me keep my patients’ records for seven years and keep them available to patients, but it says outright that it does not create or change ownership rights to medical records (MCL 333.16213). Inside a hospital’s system, the notes we write, the templates we build and the record of our own work belong to whoever runs the system we were given. A rule that has not produced a single public penalty I could find, and a right a physician does not have, look much the same to the person locked out.

In my own small private practice, the records are my patients’ and my practice’s, and I am the one responsible for them under HIPAA. In one week in Dallas, over the Lunar New Year of 2026, I wrote the code myself to connect to two major EHR platforms, over FHIR (the open standard) and their own APIs. Then came a short phone call with an undisclosed large EHR vendor about reading my own practice’s records through its official API. I agreed to keep what was discussed on that call confidential, and I am not suggesting that anything in it was improper. Federal certification rules require EHR developers to publish any fees for their certified APIs in plain language and to keep those fees tied to cost (45 CFR 170.404). I do not know whether those rules reach the access a small practice needs to read its own records.

In the hospital, the record ran on Epic through Citrix. In both places, the way I could actually read what I had written was the screen in front of me. A screenshot is the oldest interface there is: what I am already allowed to see, kept a moment longer. When capture was switched off, through Citrix and without notice, I had no way left to keep what I could already see. That is what “hostage” means here. The data was not taken; every way out of it ran through someone else’s permission.

Where the Law Stands (as of October 2026)

The short answer: largely unsettled. I found no U.S. statute, regulation or court decision that deals specifically with software restricting functions such as screen capture on a computer the worker owns. I also found no court, anywhere, that has ruled on Citrix App Protection or similar controls. A few states require notice of monitoring. Consent and scope are open questions. And in 2025 the federal agencies that had flagged worker surveillance stepped back. The NLRB’s Acting General Counsel rescinded the 2022 electronic-monitoring memo (GC 25-05). The CFPB withdrew its worker-dossier circular on May 12, 2025 (CFPB). The Government Accountability Office reported that agencies had “either rescinded these prior efforts or are reassessing” them (GAO-25-107126).

What the law clearly covers. Three states require employers to give notice of electronic monitoring: New York (Civil Rights Law §52-c, since May 7, 2022), Delaware (19 Del. C. §705) and Connecticut (Conn. Gen. Stat. §31-48d, as amended by P.A. 26-73 from October 1, 2026). Connecticut’s law reaches only collection “on an employer’s premises.”

Maine goes further. Employees there may decline an employer’s request to install data-collecting apps on their personal devices for surveillance (26 MRSA §620-A(4)). The law does not say whether this covers an app installed for another purpose, such as remote access. It is enforced only through state fines of $100 to $500 per violation, provides no private right to sue, and contains no anti-retaliation clause.

HIPAA lets a hospital choose the security measures that protect patient data, endpoint controls included (45 CFR 164.306), and a hospital’s own risk analysis may lawfully lead it to block screen capture. The rule does not require screen-capture blocking or home-network inspection (164.312).

What it does not cover. In a 2014 Texas case, a federal court threw out an employee’s federal computer-crime and stored-communications claims after his former employer remotely wiped his personal iPhone. The court left his state-law claims undecided (Rajaee v. Design Tech Homes). That is one trial-court ruling, not a general rule.

Notice laws concern collecting information. As Citrix documents it, App Protection blocks capture while a protected window is visible (Citrix).

California enacted two workplace-surveillance laws on Sept. 30, 2026, both effective Jan. 1, 2027 (Governor; summary). AB 1331 bars employers from using surveillance tools to monitor workers in workplace bathrooms. AB 1883 bars AI-driven tools that read workers’ emotions or collect neural data. As reported, neither addresses software on a worker’s own device.

What is pending. The federal Stop Spying Bosses Act (S. 4831, H.R. 9402) was introduced in June 2026. It would require employers to disclose workplace surveillance and would bar collecting workers’ data while they are off duty, including at home. Both bills were referred to committee with no further action. They die if not passed before this Congress ends in January 2027.

Michigan. I found no Michigan law that requires employers to give notice of electronic monitoring. Michigan’s general eavesdropping and hidden-camera crimes require consent to record private conversations or private places (MCL 750.539c, 750.539d). They are not workplace notice laws and say nothing about blocking screen capture.

Michigan’s Internet Privacy Protection Act bars employers from demanding the passwords to workers’ personal online accounts. It also says it does not stop an employer from monitoring data on a device the employer paid for “in whole or in part,” or data “traveling through or stored on an employer’s network” (MCL 37.275). It says nothing either way about devices the employer did not pay for.

Two bills are pending. HB 4456 would let employers monitor employees’ communications only under a written policy each employee acknowledges, and only on devices the employer owns, never on the employee’s own. HB 5579 would require notice, written consent and an opt-out, would bar collecting data while employees are off duty, and would cover the vendors employers use for monitoring. Neither bill has had a committee hearing. Both die if the Legislature ends its 2025–2026 session, usually in late December, without passing them.

Most of these laws protect “employees.” Whether they reach a physician who holds hospital privileges is itself a question, although HB 5579’s definition includes independent contractors.

Outside the U.S. Spain bars employers from requiring software on devices that regular remote workers own (Ley 10/2021, art. 17(2)). The European Court of Human Rights lists advance notice first among six factors for judging workplace monitoring. It found a violation where the national courts never asked whether the employee had been told in advance (Bărbulescu v. Romania, Grand Chamber, 2017). In a 2017 opinion, Europe’s data-protection authorities said that installing software cannot count as an employee’s consent, and that consent at work is rarely valid at all (WP249). Ontario requires employers with 25 or more employees to have a written electronic-monitoring policy that covers personal computers used for work, but it creates no right not to be monitored (Ontario).

The open question. On my own laptop, in my own house, screenshots stopped working. The hospital’s Chief of Medicine acknowledged that capture had been disabled via Citrix “just for Epic and Microsoft Outlook.” As I wrote in my earlier post, “Nobody asked. Nobody notified.” I am not accusing anyone of breaking the law. The question belongs to courts and legislators. How far may an organization’s control reach into a device it does not own? And does installing an app count as consent to whatever it is later configured to do, without notice?

I am a physician, not a lawyer. This is research, not legal advice.

What You Can Do Today

  • Ask what is installed and why. Before you install a remote-access client, a device-management profile or a “device health” agent on a computer you own, ask in writing: what does it do on my computer, what can it change, who can change its settings, and will I be told when they do?
  • Read the permissions it holds. On a Mac, System Settings → Privacy & Security lists which apps hold Screen & System Audio Recording (Screen Recording on older versions), Accessibility, Full Disk Access and Local Network access; the Profiles or Device Management pane (its place depends on the macOS version) lists installed profiles, and profiles status -type enrollment in Terminal says whether the Mac is enrolled in device management. Windows and Linux have their own equivalents.
  • Keep employer software in its own space. A separate user account keeps its permissions and its background items away from your own. A separate device is better still, and it is reasonable to ask your employer to provide one.
  • Remove it after a session. Quit the client when you finish. If you only need it now and then, uninstall it, and remove any profile you no longer need. A profile that will not let you remove it is itself worth knowing about. If your work requires the profile or client, check your employer’s policy first: removing it can end your access and may breach terms you agreed to. Ask in writing instead.

What We Are Building: Keisen Schutzhund

Schutzhund is German for “protection dog.” Keisen Schutzhund is in development; it is not available yet. One of its planned features is meant to answer one question: who else has control of this computer?

It is designed to look for:

  • device-management enrollment and configuration profiles;
  • system extensions, which run alongside the operating system and can watch processes and files, and network extensions, which can see or filter network traffic;
  • trusted certificates someone added, which can let a proxy holding the matching key read encrypted web traffic from this computer;
  • managed browser policies;
  • background agents and login items that start without you;
  • which apps hold Screen Recording, Accessibility and Full Disk Access.

For each finding it will say, in plain words, what that item can do: a capability, not an accusation. It will mark what is new since the last time you checked. It will show the standard operating-system command behind every finding, so you can check it yourself instead of trusting us. And it will help you remove or contain what you find, by revoking a permission, removing a profile or moving software into a separate account, if you choose to.

What it will not do: it will not bypass, disable or defeat a control that is running. If your employer’s software blocks screen capture inside its window, Schutzhund will tell you that the software can do that, and since when. It will not switch it off. That is a feature, not a limitation. A tool that defeats controls puts its user at odds with the agreements they signed, and in healthcare with their duty to patients’ privacy. What was missing on October 23 was not a way around the control. It was knowing.

Schutzhund is designed to run on your computer and report to you. It will show what it found and how it looked; it will not certify a computer as clean.

Request Access

Keisen Schutzhund is in development and not available yet. Like KeisenVPA, its status is “request access”: tell us what computer you use and what worries you, and it will shape what we build first.

Request access to Keisen Schutzhund · About Keisen Schutzhund →

Seeing Comes First

October 23 was my last day practicing medicine in the United States. The screenshot was not the heaviest reason; it was the last one. And the only reason I noticed is that I had built something that depended on it. Most people in that position will simply notice, one day, that something no longer works, and not know why.

The remedy starts with being able to see: who else has a hand on this computer, what that hand can do, and what changed since yesterday. After that, the decision is yours, as it should have been all along.

Posted on by omarmetwally · 1 Comment

Epic Privacy Violation. And Citrix.

The Last Screenshot

The Corewell saga, concluded

By Omar Nabil Metwally, MD
Friday, October 23, 2026

This is not satire. Oskar Rausch is on the top bench and has declined to come down for this one.

I. The Date

Friday, October 23, 2026, was my last day practicing medicine in the United States.

I would like to tell you I chose the date. I chose the year. The day chose itself, a little before sunset, on my own laptop, in my own house, while my daughter drew on the garage floor with chalk.

I am writing it down because I want to remember it accurately, because a few people have asked what happened, and because on Wednesday I sent the United States an invoice and this morning I told Corewell to go home, and a story that ends with two angry letters is not a story. It is a complaint. I have filed enough complaints. This is an accounting.

II. Wayne

Corewell Health Wayne is a small hospital. It was the last hospital where I kept privileges voluntarily, and I kept them because I liked being there. It is the kind of place where the person mopping the hallway and the chief medical officer know each other’s names, and both of them knew mine. I had been looking forward to Friday call for a week. That is a strange thing to say about call. It was true.

At 7 a.m., an hour before my shift, I called the operator to confirm I was first up for admissions and that they had my cell number. Routine. The first admission came over the phone a few hours later, and it came while I was lying on a table at a different hospital with a needle in my hip.

III. The Hip

Readers of the invoice know about the hip. For everyone else: the healthcare system I have been paying into for most of my adult life wrecked my right leg, and after a prior authorization, a deductible that could buy a used car, and several thousand dollars out of pocket, I was approved for an MR arthrogram. A radiologist injects contrast into the joint, and then you lie very still in a loud tube and think about your life. The MR arthrogram went very smoothly and surprisingly pleasantly.

That is where I was when the emergency department called. I answered on the first ring, which is the only ring there is when you are on call, and I took the admission. I am not telling you this for sympathy. I am telling you for the record: on the afternoon the system decided I was a liability, I was accepting a patient from inside an MRI.

IV. The Patient

I am going to say very little about him, because he is a real person in a real bed, and because a small hospital, a date, and a diagnosis add up to a name.

Here is what I can say. He was sick, the kind of sick that can turn in hours. He could not speak, and he could not advocate for himself. The emergency physician and I agreed on all of that in about ninety seconds. She had done the right things, fast. We called the two consultants I would call for my own family. I took him seriously, which is the only way I know how to take a patient who cannot tell you to.

By the time I got home there was an hour of daylight left. My daughter had the chalk out. The dog had a tennis ball in his mouth and an agenda. I had been looking forward to that hour since the needle went in. I went inside instead, opened the laptop, and logged in to Epic to write his note.

V. Keisen

Some context, for the pirates and the crawlers.

For about a year and a half I have practiced medicine with software I wrote. It is called Keisen. The part that reads charts and drafts notes is called KeisenVPA. The VPA stands for Voice Powered Assistant, which harkens to its roots as general-purpose computational linguistics software.

It has been for sale the whole time. Nobody has bought it. A few colleagues tried it and told me, kindly, that it did not save them any time or generate any more revenue. They were right. It takes exactly as long to write a note with Keisen as without it, and I have never earned a dollar from it. I noticed one download, from Madison, Wisconsin. I don’t know much about Madison except that Epic Systems lives there and makes the electronic health record used by most of the hospitals in America. I am not implying anything. I am noting the download. I’m sure the list of potential downloads is some random person in Madison, Wisconsin, or a VPN server in a cold, dark data center. Completely plausible.

Here is how it worked. Epic presents a human being as spreadsheets and scroll bars. On my own computer, I took screenshots of what Epic showed me, and KeisenVPA read them and handed back a draft I could actually think with: the trend that was buried in a tab, the lab from three days ago that explains the one from this morning, the thing nobody wrote down because it was in a different column. My synthesis also includes notes from all team members, including nursing notes, speech, physical, and occupational therapy, social work. Everything. It’s a comprehensive 360 degree synthesis of a patient’s state. Then I read every word. I add, I cut, I argued with it. My notes conclude with a “Teaching Point” as a rule. That’s the whole point: medical notes communicate information to colleagues, recently to the patient and family, and especially to hospital administration and payers. The ratio of the average clinical note’s utility to textual length strongly argues the case that the primary function of the note, if one judges by length and the amount of storage each note costs, is for financial reasons. Of course, every doctor knows that good documentation is essential to patient care. The reality looks otherwise.

So why spend an extra hour a day on a tool that earns nothing and saves nothing? Because it made me a better doctor. Hands down. No human being can admit twenty patients and read every number, every word, that comes in on all of them. I could. For the first time in my career, technology was working for the patient instead of for the bill, and I was, briefly, a man who looked forward to call.

A word about artificial intelligence in medicine, since everyone has one. There are no experts. The closest thing to an expert is the person who uses it every day and knows exactly where it lies. In my experience about 95 percent of what it produces in a clinical setting outperforms the human counterpart, and is better than what I would have written alone. The other 5 percent is wrong, and wrong in a confident, well-punctuated way that looks like the other 95%. That is the danger. Not the machine. The complacency. I knew this on day one, and I read every word for a year and a half because of it.

I did all of this mindful of HIPAA and of every law and regulation I could find, on a machine I control, with data that never touched a phishing link or a shared drive. I would put my handling of patient information up against any health system in the country, and I would start the comparison by asking how many times each of us has been hacked.

VI. The Last Screenshot

I opened his chart. I took my screenshots, the way I had a thousand times. I asked KeisenVPA for a draft.

It told me there were no screenshots.

I looked at the desktop. Nothing. I tried again. Nothing. And then I remembered that earlier that day, Citrix, the remote-desktop software through which Corewell serves Epic to physicians’ own computers, had asked for permission to inspect the devices on my network. I had thought that was odd. It had not asked for anything else. It had simply, quietly, made it impossible to capture an image of my own screen, on my own computer, in my own house.

Nobody asked. Nobody notified. No memo, no checkbox, no “by continuing you agree.” A health system reached through the window into a physician’s personal machine and switched off a function of it, and the only reason I noticed is that I had built something that depended on it.

I want to be precise, because precision is the whole point. I am not accusing anyone of breaking the law. I am saying that compliance and legality are different words. Compliance is whatever an institution’s policy says this quarter. The law is the law. They overlap, and they are not the same, and for a year and a half I practiced on the legal side of that line with a method the compliance side had never thought to forbid, because the compliance side had never imagined a physician doing anything with a chart except reading it slowly and billing for it.

Whoever decided to disable screen capture on an individual’s private computer, without consent and without notice, has raised a question I think belongs in a courtroom. If you practice technology or privacy law and find that question interesting, I am easy to find. I have the address. The United States writes to it every January.

VII. The Last Download

Readers of this blog may remember The Last Download, in which a physician named TooToo Medvalli stood on the roof of a parking structure and refused to install a hospital’s messaging app on his personal phone while a chief medical officer in a Brioni suit explained that it was not personal, it was optimization.

Oskar wrote that in December. It was satire. The institution wanted to put something on a doctor’s phone.

Ten months later the institution took something off a doctor’s computer. Nobody stood on a roof. Nobody wore a suit. There was no Conference Room 5-J. There was a pop-up about network devices, a shrug, and a function that had been there in the morning and was gone by dinner. The satire turned out to be a forecast with the drama left in, and Oskar has been insufferable about it all evening.

VIII. The Decision

So I sat there, with the chalk sounds coming through the garage wall, back where I had been two years ago: a tired man, now with two needle holes in his hip and counting, reading garbage spreadsheets for a patient who could not speak, knowing that I was about to practice medicine worse than I had practiced it the day before. Not because I had forgotten anything. Because someone I will never meet had decided, for reasons I will never be told, what my own computer was allowed to do.

I had not yet entered a single admission order. I never did.

I immediately called and texted the Chief of Medicine, whom I personally know and respect as one of the only Chiefs of Medicine I am more likely to see in a white coat at a computer in the doctor’s lounge than in an office because she is that kind of doctor. I have seen her at that computer since she was a medical student, and she hasn’t changed much since. I told her that I absolutely refused to take the admission. That I rely on my personal computer’s screenshot functionality to deliver excellent patient care. She acknowledged that the screenshot functionality had been disabled via Citrix “just for Epic and Microsoft Outlook.” Exactly where anyone exercising their right to collecting evidence and defending themselves in court needs screenshots. A screenshot in and of itself is not illegal. The interpretation lies to a large extent in how the screenshot is handled.

That was the last straw, and I want to be honest about what kind of straw it was. It was not the heaviest. The leg was heavier. The forty-dollar bill for my daughter was heavier. The malpractice insurer with a P.O. box in the Caribbean was heavier. This one was simply the last, and it was the last because it was the one that reached past the hospital, past the billing office, past the insurance company, and into my house. There is a point at which a system stops being something you work inside and becomes something that works inside you. I found the point. It was a screenshot.

This is not a story about Wayne. The people at Wayne are extraordinary, and I said so this morning and I will say it again here: the nurses, the physicians, the mentors, the woman at the front desk, the man who mops the hallway. They will keep doing the work. They always have. The letter I posted this morning was not addressed to them. It was addressed to the thing that owns them, and the thing that owns them is headquartered somewhere else and manages a health system the way it manages a network device.

IX. The Itemized Statement

Because this is an accounting, and because a saga on this blog does not end without one.

Code Item Amount
Z56.6 Other physical and mental strain related to work Not billed. Absorbed.
Z73.3 Stress, not elsewhere classified Elsewhere classified. See invoice of October 21.
Z75.3 Unavailability and inaccessibility of health-care facilities Carried forward
M25.551 Pain in right hip Several thousand dollars, prior authorized
Z00.CTX Screen capture, personal device, disabled without notice or consent Disputed. Pending counsel.
Z00.VPA Voice Powered Assistant, one, self-built; 18 months of superior care; 0 paying users $0.00
Z00.MSN Download, one, Madison, Wisconsin Noted
Z00.CHK Hour of daylight with daughter, chalk, and dog, Friday Not recoverable
TOTAL DUE One physician, fully licensed, board certified, clean record. Removed from circulation.

Z56.6, Z73.3, Z75.3 and M25.551 are real, billable ICD-10-CM codes. The others are proposed for the next revision, submitted to CMS by the usual route, which is to say posted here. No late fees. No collections. The account is closed.

X. Coda

I was a doctor in the United States for about fifteen years. I trained in San Francisco and Oakland, at hospitals that no longer have the names they had when I was there except on a facade and perhaps on paper. I trained and voluntarily left a fellowship in clinical informatics because I believed, with the naivet Bulbul warned me about, that a physician who could write software might make the machine serve the patient. For eighteen months, at a small hospital in Wayne, Michigan, it did.

The last thing I did as an American physician was accept a sick man from inside an MRI. The last thing the system did was reach into my house and turn off my ability to see him clearly.

The hip will be fixed somewhere with hospitals, where the premiums are called taxes and the taxes buy a hospital. The dog got his tennis ball, eventually. My daughter’s drawing is still on the garage floor, and I have decided it stays until it rains.

Go home, Corewell. I already have.

FIN

Thank you for the opportunity.

A note on what is in this essay and what is not

The patient is real. His age, his diagnosis, where he came from, and everything else that could identify him have been removed or left vague on purpose, and no detail here should be taken as clinically precise. His care was never the question; the people caring for him are the best part of this story.

Keisen and KeisenVPA are my own software. No patient data in this essay, or in that software, has ever been shared with anyone, and this essay was prepared without access to any chart. Keisenvpa.com is overdue for an update. Version 5.0.2 starts in “Linguist Mode” by default while retaining full healthcare functionality.

I am a physician, not a lawyer. Nothing here is legal advice, and nothing here accuses any person or company of a crime. It describes what happened on my computer, on one Friday, and asks a question about it. Citrix has not been reached for comment. Neither has Madison.

Posted on by omarmetwally

Go home, Corewell

Dear Corewell,

Since I started caring for patients at Corewell, the quality of healthcare services in our community has declined from barely passable to abhorrent. What you call “healthcare” is no longer recognizable as anything I learned in medical school or residency. It is blood-sucking bureaucrats telling doctors how to practice medicine. It is men in suits and a malpractice insurance company with your name that exists as an empty promise in a Carribean P.O. Box. You are living proof that justice does not exist in the United States, and that the legal system is a farce.

Due to policies that are incompatible with patient safety and well-being, I am no longer able to admit patients to your hospital. Time to put your own balls on the line, if you have any. I’ve done that long enough, and I’m tired.

Go back to Grand Rapids or wherever the hell you came from, and give us back our hospitals.

I will always be grateful to the extraordinary physicians, nurses, and mentors that I had the opportunity to work with and learn from over the years. You inspire me.

Sincerely,

Omar Nabil Metwally, M.D.

Internal Medicine Physician and Healthcare Litigator

Posted on by omarmetwally

Invoice to the United States of America

October 21, 2026

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.
FromOmar Nabil Metwally, MD, Ypsilanti, Michigan. You have the address. You write to it every January.
ToThe United States of America, c/o Department of the Treasury, 1500 Pennsylvania Avenue NW, Washington, DC 20220
CopyHealth Insurance Marketplace, 465 Industrial Boulevard, London, Kentucky 40750-0001, the return address on every form cited below
DateOctober 21, 2026
TermsNet 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 yearMonths coveredPremiums I paid, net of your creditsHealth share of my federal income tax, 31.2%Interest, 7% compounded daily from Dec 31Line total
2018May–Dec$1,708.72$4,495.92$4,514.30$10,718.94
2021Jan–Mar$941.16$5,854.99$2,719.13$9,515.28
2022Jan–Sep$1,173.78$3,221.71$1,342.61$5,738.10
2023Jan–Dec$1,519.32$5,521.15$1,529.22$8,569.69
2024Jan–Dec$6,728.16$6,908.30$1,836.88$15,473.34
2025Jan–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

ItemAmount
Global Entry fee, nonrefundable$120.00
Right leg, one, previously functionalNot billed here. That invoice goes to someone else.

TOTAL DUE: $68,283.28

Notes

  1. 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.
  2. 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.
  3. 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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  • Tax Foundation, The Spiraling Cost of Federal Healthcare Subsidies and Carveouts, September 2026: federal health spending of $2.18 trillion in 2025, 31.2 percent of the federal budget, from OMB’s historical tables.
  • IRS, IR-2026-98, August 21, 2026: 7 percent, compounded daily, for individual underpayments in the quarter beginning October 1, 2026.
  • IRS, Failure to Pay Penalty: 0.5 percent of unpaid tax per month, up to 25 percent, with interest charged on penalties.
  • 26 U.S.C. § 6702: a $5,000 civil penalty for frivolous tax returns and specified frivolous submissions.
  • Peterson-KFF Health System Tracker, How does health spending in the U.S. compare to other countries?, March 11, 2026: $14,775 per person in the United States in 2024, against $7,860 in comparable countries.
  • 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.
Posted on by omarmetwally

On Professionalism: A Dropped Towel and Feedback in Medicine

A Reflection on Feedback

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.

Posted on by omarmetwally

The Match

A sequel, with one interruption

By Omar Nabil Metwally, MD

First published 11 October 2026

I. The Review

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.

Spirit went out of business this May. The loans, I assume, are still in the air.

IV. The Match

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.

Thank you for the opportunity.

Posted on by omarmetwally

Experience and Reference

An essay on writing, dictated, with interruptions

By Omar Nabil Metwally, MD

First published 10 October 2026

I. The Letter

My writing career began with a thank-you note.

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.

Posted on by omarmetwally

Löyly and Order

A Tale of Finnish Jurisprudence

Preface

By Omar Nabil Metwally, M.D.

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.

FIN

— Oskar Rausch, written from the top bench

Posted on by omarmetwally

Indifference and Incompetence

A Tale of American Ingenuity
by Oskar Rausch

This is a work of satire and fiction.

I. The Partnership

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.

FIN