Healthcare – Minimally invasive software

A Medical Tragicomedy

By Dr. TooToo Medvalli, MD

“The boycott had been comprehensive, almost impressive in its coordination.”

DISCLAIMER

This is a work of satire inspired by real events in American healthcare employment. All characters, names, and identifying details have been changed. Any resemblance to actual persons, living or dead, or actual organizations is purely coincidental. The legal cases and public records cited (Cascade Health Solutions v. PeaceHealth, wage theft settlements, etc.) are matters of public record and documented fact. The author’s experiences with healthcare employment negotiations are real. The names are not.

PART I: THE VIEW FROM THE CRUISE SHIP

Chapter 1: Welcome to Gravina Island

The thing about watching your professional life collapse from a houseboat anchored off Gravina Island is that you have plenty of time to consider the absurdity of it all. Which is exactly what I was doing at 6:47 AM on a Tuesday morning when the Norwegian Joy glided past, its passengers waving cheerfully at the picturesque Alaskan landscape while I stood on my floating prison in my bathrobe, holding a cup of instant coffee and contemplating the series of decisions that had led me here.

Dr. TooToo Medvalli, MD. Board-certified gastroenterologist. Three months into my “opportunity” with PeaceHealth Ketchikan Medical Center. Living on a houseboat because even the marina operators had refused my business.

The boycott had been comprehensive, almost impressive in its coordination. No landlord would rent to me. Grocery stores turned me away at the door—politely, always politely, with that particularly Alaskan brand of courtesy that made rejection feel like a favor. Even the dispensaries claimed to be out of stock. The ferry operators, those stoic civil servants, found creative reasons why I couldn’t board. “System’s down.” “Weight limits.” “Weather advisory.”

It was remarkable, really, how a community of 8,000 souls could mobilize against one physician who’d had the audacity to—

Well. We’ll get to that part.

I waved back at the cruise ship passengers. Force of habit. They couldn’t see me anyway, but I’d developed this peculiar routine over the past three months. Wave at the tourists. Remind yourself you’re still visible. Still human. Still technically a physician, though increasingly unclear what that actually meant in Ketchikan.

My phone buzzed. An email from Mupeet, the PeaceHealth recruiter who’d promised me this would be a “seamless transition” to “Alaska’s premier healthcare destination.”

Subject: RE: Contract Amendment Request – Mutual Attorney Fees Provision

I didn’t need to open it to know what it said. The same thing every email from PeaceHealth said, in increasingly creative variations: We have a standard contract for all 1,300 physicians.

As if repeating a number made something true. As if 1,299 other physicians signing a terrible contract somehow obligated me to do the same. It was the logical equivalent of saying “well, everyone else jumped off the cliff, so you should too,” except dressed up in corporate HR language and delivered with the cheerful insistence of someone who’d been trained to never acknowledge that they were, in fact, asking you to jump off a cliff.

But I’m getting ahead of myself. This story doesn’t start on a houseboat off Gravina Island. It starts the way all medical disasters start: with hope, enthusiasm, and a completely unrealistic expectation that institutions designed to extract value from physicians might actually treat physicians like human beings.

Let me back up.

Chapter 2: How I Learned to Stop Worrying and Love the Credentialing

JUNE 2025

“Dr. Medvalli, we’re so excited to have you join the PeaceHealth family!”

Mupeet’s voice on the phone had that particular pitch of enthusiasm that immediately made me suspicious. I’d been a physician long enough to know that when healthcare administrators used words like “family” and “exciting opportunity,” what they actually meant was “we’re about to make your life significantly more complicated and then act surprised when you’re not grateful.”

But I was optimistic. Foolishly, embarrassingly optimistic. Ketchikan needed physicians. I was a physician. Simple supply and demand, right? Economics 101. What could possibly go wrong?

“I just need you to complete your credentialing application through VerityStream,” Mupeet continued. “It’s very straightforward. Most physicians finish it in one sitting.”

Famous last words.

VerityStream, for the uninitiated, is what happens when someone decides that the already byzantine process of medical credentialing could be made worse through digitization. It’s a platform that manages to combine the user-unfriendliness of a 1990s website with the reliability of a dial-up modem, all wrapped in the kind of interface design that makes you wonder about healthcare systems’ choice of software.

I logged in. Or tried to. The VPN I use for security—standard practice for anyone who doesn’t want to broadcast their medical license information across open WiFi networks—was blocked. No error message. No explanation. Just… blocked.

I tried a different U.S.-based VPN server. Blocked.

I tried without a VPN. The page loaded, then immediately crashed.

I tried a different browser. Same result.

I tried my phone. The login page appeared, but when I entered my credentials, I got an error message that appeared to be in some kind of ASCII art font that made it completely illegible.

Four hours later, I’d made it through exactly one page of the application: my name and date of birth.

I emailed Mupeet: “Having some technical difficulties with VerityStream. Is there a PDF version I could complete instead?”

Her response: “VerityStream is our standard platform for all credentialing. Please continue with the online application. We don’t have a PDF version.”

Standard. There was that word again. I was beginning to understand that “standard” in healthcare administration meant “we’ve done it this way for so long that we’ve forgotten why we started, and we’re certainly not going to change now just because it doesn’t work.”

But I persevered. Because that’s what physicians do. We persevere. We adapt. We find workarounds for broken systems because patients need us to, and because somewhere in the back of our minds, we still believe that if we just work hard enough, if we just push through enough bureaucratic nonsense, we’ll eventually get to do the thing we trained for: actually taking care of people.

Three weeks. It took me three weeks to complete the VerityStream application. An application that should have taken, as Mupeet had so confidently assured me, “one sitting.”

The problems were endless:

The Oregon State Initial Credentialing Application wouldn’t generate
The PeaceHealth Attestation Questions section refused to show a green checkmark no matter how many times I submitted it
My professional references kept showing as “incomplete” even though all three colleagues had confirmed they’d submitted their forms
The system randomly logged me out mid-session, deleting unsaved data
Half the dropdown menus didn’t work in Safari, Chrome, or Firefox

I documented everything. Screenshot after screenshot. Error message after error message. I was building a case, though I didn’t yet realize what kind of case I’d eventually need.

On July 15th, I finally submitted the completed application. I felt the peculiar satisfaction that comes from finishing something that shouldn’t have been difficult but was made artificially complicated by technological incompetence masquerading as innovation.

Mupeet’s response: “Great! Now we just need you to resubmit your professional references.”

I stared at my computer screen for a full minute, trying to process this sentence.

“The references were already submitted,” I replied. “Dr. Russell, Dr. Khanna, and Dr. Augustino all completed their forms three weeks ago.”

“I know, but that round of references was just to start the job application. For credentialing, you’ll need to submit 3 new references that are different from the ones we required to consider your job application.”

So a prospective doctor has to submit 3 peer references just to knock on PeaceHealth’s door, and then when they finally get to the credentialing process, a few steps before the finish line, they have to submit 3 entirely new physician references? No. No, I will not. Because asking busy physician colleagues to duplicate work they’d already completed due to PeaceHealth’s system failures was:

Unprofessional
Disrespectful to my colleagues
A sign that I was entering a relationship with an organization that fundamentally didn’t value physicians’ time

But I didn’t say that. Not yet. Instead, I wrote: “I will not ask my references to duplicate work they’ve already completed due to internal system issues on PeaceHealth’s end. The references were submitted in good faith by respected colleagues who took time from their busy schedules to support my application. Please retrieve them from your system.”

Three days of silence.

Then: “We’ve located the references. Thank you for your patience.”

The references had been there all along. In the system. Filed correctly. But the recruiting team apparently didn’t communicate with the credentialing team, each of them trying to operate their own systems without any cross-talk. It was more convenient for the credentialing team to ask for three new references than to ping colleagues from the recruiting team. Oblivion, laziness, apathy. Someone asleep in the cockpit.

This should have been my first warning sign.

It was not my last.

Chapter 3: The Credentialing Morass

AUGUST 2025

By mid-August, I’d exchanged 77 emails with four different people at PeaceHealth, an organization 800 miles and an ocean away from Ketchikan, none of whom seemed to know what the other three were doing, and all of whom had slightly different ideas about what documentation I needed to provide.

Dora Nuss (Credentialing Specialist): “We need your UCSF training certificate.”

Linda Waters (Senior Credentialing Coordinator): “Actually, we need a letter from UCSF explaining the gap in your training.”

Mandy Harbor (Credentialing Manager): “We need verification of all hospital affiliations since completion of training.”

Sandra Koch (Chief Administrative Officer): “You can apply for hospital privileges as an independent doctor. No problem. You need a place of business.”

“No problem. I’m actually working on it now,” I replied.

“Just so you know though, you couldn’t cover your own patients if they were admitted, because we have 24/7 physican coverage already. And there would be no reimbursement from us for you to do so. Because we’re not looking for someone to cover. Everyone who works in the hospital is employed by PeaceHealth Medical Group.”

I let that sit for a moment. Then: “So you’re saying that hospital privileges—and the ability to practice medicine in Ketchikan—are conditional on employment with PeaceHealth Medical Group?”

Koch: “I’m saying that’s how we operate. All our doctors are PeaceHealth employed. If you wanted to be an independent practitioner and also have hospital access, that would be… complicated.”

Complicated. That word again. The word organizations use when they mean “impossible but we can’t say impossible because that would be illegal.

“Ms. Koch, Ketchikan Medical Center is the only hospital within 235 miles. If I can’t have privileges there as an independent physician, I can’t practice medicine in Ketchikan at all. Are you aware that tying hospital privileges to employment might constitute an antitrust violation?”

Silence. Longer this time. “Dr. Medvalli, I’m just explaining how our system works. If you want to work here, you’ll need to be employed by PeaceHealth Medical Group. That’s the structure we have.”

“Right. The structure where the only hospital on an isolated island only grants privileges to physicians who agree to be employed by your medical group. The structure that effectively eliminates any possibility of independent practice or competition.”

“But I want to be very clear about what you’ve just told me: PeaceHealth Ketchikan Medical Center does not grant privileges to independent practitioners. Is that correct?”

“That’s… that’s how we currently operate, yes.”

“And has it always been this way? Have there ever been independent practitioners with privileges at Ketchikan Medical Center?”

Another pause. “Not that I’m aware of. Not in my time here.”

“How long have you been here?”

“Nineteen years.” Nineteen years. Nineteen years of a monopoly hospital on an isolated island ensuring that no physician could practice medicine without submitting to employment by their medical group. This wasn’t a credentialing conversation anymore. This was evidence.

By September, the email count had reached 93. I’d been in contact with five different coordinators. My start date had been pushed back from October 1st to November 1st to December 1st to “TBD pending credentialing completion.”

And then came the Teams meeting.

Chapter 4: The Teams Meeting, or: How I Learned That Corporate Healthcare Runs on Meetings About Having Meetings

SEPTEMBER 16, 2025

“Dr. Medvalli, thank you so much for joining us!”

Dr. Rajesh Jade, PeaceHealth’s VP of Medical Operations, beamed at me from my laptop screen. Beside him were Dora, Linda, Mandy, and two people I’d never heard from before: Patricia Rice (VP of Legal) and someone whose name and title I immediately forgot because my brain had reached maximum capacity for PeaceHealth administrators.

“We wanted to touch base about your credentialing progress,” Dr. Jade continued, using the phrase “touch base” in that way that means absolutely nothing while sounding productive.

“Yes,” I said. “I wanted to touch base too. Specifically about why, after three months and 93 emails, my credentialing isn’t complete despite the fact that I’ve provided every piece of documentation requested, sometimes multiple times.”

Uncomfortable silence. Faces on screens trying to figure out who should speak first. Finally, Dora jumped in.

“Well, you see, there were some issues with the VerityStream system—”

“Yes, I’m aware of the VerityStream issues. I documented them extensively. I also offered multiple times to complete a PDF application instead. That offer was declined. You said you’d contact the software vendor but there was no follow up.”

“The PDF isn’t our standard process,” Mandy interjected. “We use VerityStream for all physicians.”

There it was again. Standard. The magic word that excused all sins.

“I understand it’s your standard process,” I said, keeping my voice carefully level. “But your standard process doesn’t work. The VerityStream website is fundamentally broken. The Oregon credentialing application won’t generate. The attestation section won’t accept completed forms. The system logs out randomly and deletes data. I’ve been screen-recording all of this. Would you like me to send you the footage?”

More uncomfortable silence.

“We’ll look into the technical issues,” Dr. Jade said, in the tone of someone who absolutely would not look into the technical issues.

“Great. While you’re looking into that, can someone explain why I was asked to resubmit professional references that were already in your system?”

“That was a communication error,” Linda admitted. “The references were there, we just… there was confusion about where they were filed.”

“A three-week confusion that resulted in me nearly asking three busy physicians to duplicate work they’d already completed.”

“We apologize for that,” Dr. Jade said. He didn’t sound apologetic.

“And can someone explain why I’m still waiting for a single point of contact? I’ve been working with five different people, all asking for slightly different things, none of whom seem to know what the others have requested.”

“We’re assigning you a dedicated coordinator,” Mandy said.

“When?”

“Soon.”

“That’s not a date.”

“This week.”

“Which day this week?”

She looked uncomfortable. “I’ll get back to you on that.”

I took a breath. “Dr. Jade, I want to be very clear about something. I’ve been extraordinarily patient. I’ve accommodated every request, even the unreasonable ones. I’ve worked with your broken systems. I’ve waited through multiple start date delays. But my family is in limbo. We were supposed to relocate to Ketchikan in October. It’s now mid-September, and I don’t have a firm start date. I don’t have credentialing completion. I don’t even have a single person I can email who can give me a straight answer about where we are in this process.”

Dr. Jade nodded sympathetically. “I completely understand your frustration, Doctor. We’re going to streamline this. Patricia will coordinate with medical staff services. We’ll have weekly check-ins. And we’ll assign you that single point of contact by end of week.”

I didn’t believe him, but I nodded anyway.

The meeting ended with the usual pleasantries. Everyone thanked everyone else for their time. Plans were made. Commitments were voiced.

And absolutely nothing changed.

The dedicated coordinator never materialized. The weekly check-ins never happened. Patricia from Legal never emailed me.

What I did get was another request to resubmit my hospital affiliation history, despite having already provided my complete CV, which contained my hospital affiliation history.

“Should I just send you my CV again?” I asked Linda via email.

“Yes, but we need it in a specific format.”

“What format?”

“Chronological, with dates and roles.”

“That’s… that’s what a CV is.”

“Right, but we need it formatted specifically for credentialing.”

“Which means what, exactly?”

No response for four days.

Then: “Never mind, we found it in your file.”

Chapter 5: Enter Sandra Koch, or: The Woman Who Could Kill Your Career With a Smile

OCTOBER 1, 2025

By early October, the contract negotiation track had collided with the credentialing track in a perfect storm of bureaucratic dysfunction.

I’d been working with Mupeet on my employment contract. And by “working with,” I mean “trying to negotiate with someone who’d been explicitly told she had zero authority to negotiate anything.”

The contract had several problems. Not minor problems. Fundamental, “I-cannot-sign-this-document” problems:

1. Attorney Fee Provision: The contract stated that if there was any dispute, PeaceHealth could recover their legal fees from me, but I couldn't recover mine from them. Ever. Under any circumstances. Even if I won.

2. FTE Definition: The contract didn't define what "1.0 FTE" actually meant—how many hours, how many patients, what constituted full-time work. This left me completely vulnerable to PeaceHealth changing expectations after I'd relocated. "You're 1.0 FTE, but we need you to see 30 patients a day now." No protection.

3. Outside Professional Activities: I run a medical technology LLC that develops practice management software. Completely separate from clinical practice. No patient data. No PeaceHealth resources. My own time, my own money. The contract required PeaceHealth approval for any outside professional activities, with approval subject to their "integrity team" review. No defined criteria. No timeline. No appeals process.

4. Start Date Rigidity: The contract specified December 1^st as my start date, with no flexibility language despite the fact that their credentialing delays had already pushed back my original October start date by two months.

I consulted a trusted attorney whom I had previously worked with on other contract-related matters. The attorney – call him N – reviewed the contract and gave me a list of recommended modifications. All of them were reasonable. Some were generous on my part—I was willing to accept a lot of standard clauses that my attorney thought were problematic.

But the attorney fee provision? That was my line in the sand.

“I cannot sign a contract where I would have to pay a huge corporation’s legal fees while they have no obligation to pay mine,” I told Mupeet in one of our many phone calls. “That’s fundamentally unfair.”

“I understand,” she said, “but that’s our standard contract language.”

“Just because something is standard doesn’t make it fair.”

“I know, but we have 1,300 physicians, and they all have the same contract.”

“Maybe you have 1,300 physicians with terrible contracts.”

Silence. Then: “I’ll escalate this to Dr. Leigh.”

Dr. Marvin Leigh. Chief Medical Officer. The man who supposedly had authority to modify contracts that recruiters claimed were written in stone.

Dr. Leigh called me on September 2nd.

“Dr. Medvalli, Marvin Leigh here. How are you?”

“I’m well, thanks. How are you, Dr. Leigh?”

“Doing great. Listen, Mupeet tells me you’re having some concerns about the contract?”

I walked him through my requests. The attorney fee provision. The start date flexibility. The outside professional activities clarification. The definition of 1.0 FTE, which was mysteriously absent from the contract despite supposedly being the cornerstone of my employment.

Dr. Leigh listened. Actually listened, which was refreshing. And then he said something that made me think maybe, just maybe, this would work out:

“These all sound pretty reasonable to me. The attorney fee thing, I’ll be honest, I’m not even sure what the current language says. Let me look into that. The FTE definition—we definitely have that documented somewhere, we should have it in the contract. Start date flexibility, that’s not a problem, we adjust those all the time.”

“Really?”

“Really. Look, Doctor, we want you here. You’re qualified, you’re needed, and I don’t see any reason why we can’t work through these contract details. Give me a week to talk to legal and I’ll get back to you.”

I felt hopeful. Genuinely hopeful. Dr. Leigh seemed like a reasonable human being who understood that physicians are people, not interchangeable cogs in a machine.

This feeling lasted approximately six days.

On September 8th, I got an email from Mupeet.

Subject: Contract Update

Hi Dr. Medvalli,

I heard back from Dr. Leigh and our legal team. Here’s where we landed on your requests:

1. Attorney Fee Provision: We’ve modified this to be mutual! Now neither party can recover attorney fees. We think this addresses your fairness concern.

2. FTE Definition: Dr. Leigh said we’ll include this documentation in your onboarding materials.

3. Start Date Flexibility: If credentialing causes delays, we’ll work with you. But we can’t change the contract language.

4. Outside Professional Activities: The integrity team will review and get back to you.

Let me know if you’re ready to move forward, and I’ll send a revised employment agreement!

—Mupeet

I read this email three times, trying to parse what had happened.

The attorney fee provision had been made “mutual” in the worst possible way. Instead of both parties being able to recover fees if they won, now neither party could recover fees. Ever.

This was presented as a compromise. As “fair.”

But it wasn’t fair. It was worse for me.

Here’s why: If I had to sue PeaceHealth for breach of contract, I’d be hiring an attorney out of pocket. Let’s say I spent $50,000 on legal fees. If I won, I’d still be out $50,000.

Meanwhile, PeaceHealth has in-house legal counsel. Their lawyers are salaried employees. A lawsuit costs them basically nothing marginal.

So the “mutual” provision wasn’t mutual at all. It removed a protection from me (the ability to recover fees if I won) while not imposing any real burden on them (because they don’t need to hire outside counsel).

I called Mupeet.

“This isn’t what I asked for,” I said.

“But it’s mutual now! Neither party pays the other’s fees!”

“That’s not the same as both parties being able to recover fees if they win.”

“But… it’s equal.”

“Mupeet, PeaceHealth has in-house counsel. You have unlimited legal resources. I don’t. This change benefits you, not me.”

“I’ll… I’ll escalate this back to Dr. Leigh.”

Meanwhile, the credentialing situation had reached new levels of absurdity. I was now corresponding with six different people. My email count had hit 90+. And I still didn’t have a firm start date.

That’s when I got The Call.

Sandra Koch. Chief Administrative Officer of PeaceHealth Ketchikan Medical Center. The final boss.

“Dr. Medvalli, this is Sandra Koch. I wanted to reach out personally about your situation.”

Her tone was friendly. Almost maternal. This should have been my warning.

“I understand you’re frustrated with the credentialing process,” she continued. “And I want you to know we’re doing everything we can to get you started. But I also wanted to make sure we’re on the same page about your role here.”

“Of course. I’m here to be a gastroenterologist. To see patients. To provide care that this community clearly needs.”

“Right. And you’ll be employed by PeaceHealth Medical Group?”

“That’s what we’ve been negotiating, yes.”

“Good. Because I did see your email about applying for independent hospital privileges. I wanted to clarify something.” Her voice changed slightly. Still friendly, but now with an edge. “All of our doctors are PeaceHealth employed.”

I felt something cold settle in my stomach.

“Regardless of the outcome of our employment negotiations,” I said carefully. “I’d like to apply for hospital privileges as an independent physician. In any case, it would put me in a better position to negotiate with PeaceHealth and open the door to me joining the community as a private practice doc in the event we can’t reach an employment agreement.”

“I understand. But you should know that we don’t have independent practitioners with privileges here. Everyone who works in the hospital is employed by PeaceHealth Medical Group.”

There it was. Explicit. Clear. Undeniable.

“Are you saying that hospital privileges are conditional on employment with PHMG?”

“I’m saying that’s how we operate. All our doctors are PeaceHealth employed. If you wanted to be an independent practitioner and also have hospital access, that would be… complicated.”

Complicated.

“Complicated how?”

“Well, you couldn’t cover your own patients if they were admitted, because we have 24/7 physician coverage already. And there would be no reimbursement from us for hospital work since we’re not looking for additional doctors. So it would be complicated.”

I understood perfectly. It wasn’t complicated at all. It was simple:

No employment = No privileges.

The hospital was the only hospital within 235 miles. If you wanted to practice medicine in Ketchikan, you worked for PeaceHealth. If you didn’t work for PeaceHealth, you didn’t practice medicine in Ketchikan.

Simple.

Chapter 6: The Antitrust Awakening

That night, I couldn’t sleep. Not because I was angry—though I was—but because something Sandra Koch had said was nagging at me.

“All our doctors are PeaceHealth employed.”

Not “most.” Not “we prefer.” All.

I did what any physician with insomnia and internet access does: I started researching.

Turns out, PeaceHealth has quite a history with antitrust law.

CASCADE HEALTH SOLUTIONS v. PEACEHEALTH (2003-2008)

In Lane County, Oregon, McKenzie-Willamette Hospital sued PeaceHealth for attempted monopolization. PeaceHealth operated three hospitals and dominated the market for primary, secondary, and tertiary hospital care. McKenzie operated one small hospital and provided only primary and secondary care.

PeaceHealth offered insurers bundled discounts: Use us exclusively for ALL services, and we’ll give you a 15% discount. Use us for tertiary care but let McKenzie provide primary/secondary care? Only 10% discount.

The result: Insurers couldn’t afford to include McKenzie in their networks. McKenzie was being squeezed out not because they provided worse care or charged more, but because they couldn’t match PeaceHealth’s bundled pricing—they didn’t offer tertiary services.

A jury found PeaceHealth guilty of attempted monopolization and awarded McKenzie $16.2 million in trebled damages.

The Ninth Circuit Court of Appeals later vacated the verdict on technical grounds about jury instructions, but notably did NOT find that PeaceHealth’s conduct was legal. They just sent it back for retrial under a different legal standard.

The case eventually settled. Quietly. As these things do.

The message was clear: PeaceHealth has a history of using its monopoly power to exclude competitors, even when doing so harms patients and violates antitrust law.

But that wasn’t all.

I found more:

PEACEHEALTH WAGE THEFT SETTLEMENTS

2023: Settled class action for $7.3 million for timecard rounding system that systematically underpaid 11,000 healthcare workers
Multiple employees sued claiming PeaceHealth pressured them to clock in/out at times that favored the company in wage calculations

PEACEHEALTH CHARITY CARE VIOLATIONS

Washington Attorney General: PeaceHealth agreed to return up to $13.4 million to low-income patients who were billed despite qualifying for financial assistance
PeaceHealth had failed to inform thousands of patients about available charity care, despite legal requirements

DISCRIMINATION LAWSUITS

ACLU-WA: Sued for denying transgender healthcare coverage to employees
Sexual assault lawsuit: Patient alleged aggressive tactics by PeaceHealth legal team to intimidate and discredit assault victims

This wasn’t one bad incident. This was a pattern.

At 3 AM, I drafted an email to N, my attorney.

I need to talk to you about antitrust issues. I think PeaceHealth is tying hospital privileges to employment with their medical group. Sandra Koch, the CAO, explicitly told me “all our doctors are PeaceHealth employed” and that independent practice with hospital access would be “complicated.”

Given that PeaceHealth Ketchikan is the only hospital within 235 miles, and Ketchikan is only accessible by plane or boat, this effectively means you either work for PeaceHealth or you don’t practice medicine here.

Isn’t that textbook tying? And possibly exclusive dealing?

Call me when you can.

—TooToo

I hit send and tried to sleep.

I couldn’t.

Because I’d just realized something else: If PeaceHealth was willing to tie privileges to employment, if they had a documented history of anticompetitive conduct, if they’d already been sued successfully for monopolistic practices…

What the hell was I walking into?

Chapter 7: The Great Escape (That Wasn’t)

OCTOBER 15, 2025

N called me the next morning.

“TooToo, I read your email. Tell me exactly what Sandra Koch said.”

I recounted the conversation. Verbatim. When you have anxiety and a good memory, you remember conversations in excruciating detail—a dubious superpower, but occasionally useful.

“‘All our doctors are PeaceHealth employed,'” N repeated. “She said all?”

“Yes.”

“Not ‘most’ or ‘currently’? She said all?”

“All. And she said independent practice with hospital privileges would be ‘complicated’ and there would be ‘no reimbursement’ for hospital work.”

Silence on the other end. Then: “That’s pretty explicitly exclusionary.”

“That’s what I thought.”

“And given that it’s the only hospital in the region, this is potentially a tying arrangement. You want hospital privileges? You have to buy the employment contract. Classic antitrust violation.”

“So what do I do?”

“Well, you could sue them.”

I laughed. It wasn’t a happy laugh.

“N, I’m trying to START a job, not blow up my career before it begins. If I sue PeaceHealth before even starting work, I’ll be radioactive. No hospital will touch me. I’ll be ‘that doctor who sues employers.'”

“I know. But you need to understand something: What they’re doing is illegal. Tying is a per se antitrust violation under the Sherman Act. Hospital privileges are essential for practicing medicine. They can’t condition access on employment.”

“Except they’re doing exactly that.”

“Yes. They are. Which means you have three options:”

“I’m listening.”

“Option one: Sign the contract. Work for them. Accept that you’re entering an organization that operates illegally and hopes no one challenges them.”

“Pass.”

“Option two: Walk away. Forget Ketchikan. Find another position somewhere else.”

I thought about my family. About the months of preparation. About the fact that I’d turned down other opportunities because I’d committed to PeaceHealth. About the genuine need for medical services in Ketchikan—a community that deserved better care than they were getting.

“What’s option three?”

“Option three: You document everything. Keep every email. Record every conversation. Build a case. And when they inevitably screw you over—and TooToo, they will—you sue them. Not for breach of contract. For antitrust violations.”

“That’s not really a better option.”

“No. It’s not. But at least you’d be holding them accountable. And you might get other physicians out of similarly terrible situations.”

I sat with that for a moment.

“N, I just want to practice medicine. I don’t want to be an antitrust crusader.”

“I know. But sometimes physicians don’t get to choose.”

That night, I opened my email and started a new folder: “PeaceHealth – Evidence.”

I began systematically organizing every email. Every Teams meeting minutes. Every phone call note. The VerityStream screenshots. The contract versions. The credentialing requests and re-requests. Sandra Koch’s explicit statement about employment requirements.

I wasn’t planning to sue. Not yet. Maybe not ever.

But I was going to be ready.

Chapter 8: The Contract Theater

OCTOBER 20-30, 2025

The contract negotiations had devolved into farce.

Every time I raised a concern, Mupeet would “escalate to Dr. Leigh.” Days would pass. Then I’d get a response that either: a) Completely missed the point of my concern b) Offered a “solution” that was actually worse than the problem c) Claimed they’d “looked into it” but couldn’t change “standard language”

The attorney fee provision was the perfect example.

Version 1 (Original): PeaceHealth can recover legal fees from me. I cannot recover legal fees from PeaceHealth.

Version 2 (After “Negotiation”): Neither party can recover legal fees.

What I Actually Wanted (Version 3): BOTH parties can recover legal fees if they prevail.

This is not complicated. Mutual protection. If you sue me and lose, you pay my legal fees. If I sue you and lose, I pay your legal fees. Fair. Symmetric. Normal in professional contracts.

But PeaceHealth treated this request like I was asking them to donate a kidney.

“We’ve never done that in any employment contract,” Mupeet said.

“Maybe you should start.”

“It’s just not our practice.”

“Your practice is unfair.”

“But it’s standard.”

We were going in circles. Expensive, time-consuming circles.

Then came the piece de resistance: The start date issue.

Remember, my original start date was October 1st. Then November 1st. Then December 1st. All because of theircredentialing delays.

My attorney had suggested adding language like: “December 1, 2025, or such later date as mutually agreed in writing.”

Simple. Acknowledges reality. Protects both parties if there are further delays.

Mupeet’s response: “We can’t change the start date language in the contract. But don’t worry—if credentialing causes delays, we’ll work with you.”

“But you won’t put that in writing?”

“We don’t need to. We adjust start dates all the time.”

“Then why not put it in the contract?”

“Because it’s not our standard language.”

I wanted to have a heart-to-heart with my boxing dummy, Bob. Instead, I wrote a very professional email explaining that “we’ll work with you” is not a contract term, it’s a verbal assurance, and verbal assurances from organizations that can’t even manage their own credentialing system are worth approximately nothing.

No response for a week.

Then: “Dr. Leigh says we can’t modify the start date language, but he assures you that if there are delays, we’ll accommodate them.”

Dr. Leigh’s assurance. As if I could take that to court. “Your Honor, I know the contract says December 1st, but Dr. Leigh assured me…”

NOVEMBER 1, 2025

November arrived. No contract. No credentialing completion. No start date.

I sent an email to Dr. Leigh directly.

Dr. Leigh,

I need clarity. It’s now November. I was originally supposed to start in October. My start date has been pushed back twice due to credentialing delays that are entirely on PeaceHealth’s end—not mine. I’ve provided every piece of documentation requested, multiple times.

I still don’t have a signed contract because PeaceHealth refuses to include basic fairness provisions like mutual attorney fee recovery.

I need you to tell me, directly: Is PeaceHealth actually committed to bringing me on? Or are we just going through motions here?

Because from where I’m sitting, it looks like your organization wants physicians who will sign anything, ask for nothing, and accept being treated as expendable.

I’m not that physician. But I am a good physician who wants to serve Ketchikan. So please: Either work with me in good faith, or tell me now so I can move on.

Respectfully, Dr. TooToo Medvalli

I hit send and immediately regretted the tone. Too harsh? Too honest?

No. It needed to be said.

Dr. Leigh called me two hours later.

“Dr. Medvalli, I got your email.”

“And?”

“And… you’re right. This process has been messier than it should be. I apologize for that.”

I said nothing. Waiting.

“Look,” he continued, “we want you here. We do. But I’m going to be honest with you: The attorney fee provision isn’t going to change. It’s been reviewed by our legal team, they’ve given us their position, and I don’t have authority to override that.”

“Even though it’s fundamentally unfair?”

“I understand your position. But it’s the same language we use for all our physicians.”

“Dr. Leigh, with respect, ‘everyone else has a bad deal’ is not a compelling argument for why I should accept a bad deal.”

“I know. But it’s where we are.”

Silence.

“So what are you saying?” I asked. “That this is the final offer?”

“I’m saying this is the contract we have. And if you want to work for PeaceHealth, this is what it looks like. I wish I could give you different news. But I can’t.”

“Then I guess we’re done.”

“TooToo—”

“Dr. Medvalli.”

“Dr. Medvalli. Don’t make a hasty decision. Think about it. Sleep on it. We can talk next week.”

“There’s nothing to think about, Dr. Leigh. I’m not signing a contract that lets you take me to court and stick me with both sides’ legal bills if I win. That’s not ‘standard.’ That’s unconscionable.”

“I understand. But—”

“No. You don’t understand. You have a legal team. You have resources. You have 1,300 physicians to absorb risk across. I’m one person. If we have a dispute and I’m right, and I win, I should be able to recover my legal costs. That’s basic fairness. And the fact that PeaceHealth won’t agree to that tells me everything I need to know about how you treat physicians.”

Silence on the other end.

“I’m sorry you feel that way,” Dr. Leigh said finally.

“I’m sorry you run an organization that makes physicians feel this way.”

I hung up.

Chapter 9: The Aftermath, or: How I Learned That Winning Is Also Losing

NOVEMBER 5-7, 2025

For three days, I heard nothing from PeaceHealth.

I assumed it was over. I’d walked away. They’d let me walk. That was that.

I started looking at other positions. The Midwest. California. Colorado. Places where I wouldn’t be at the mercy of a single employer in an isolated community. Places where “no” actually meant something and contracts were negotiable.

Then, on November 7th, I got an email from Patricia Rice. VP of Legal. The woman who’d never contacted me during the entire credentialing process but who apparently had time now.

Subject: Path Forward

Dr. Medvalli,

Dr. Leigh shared with me your concerns about the employment agreement. I wanted to reach out directly to see if we can find a resolution.

While we cannot modify our standard attorney fee language, we would be willing to add a clause specifying that any disputes must go through binding arbitration rather than litigation. This would substantially reduce legal costs for both parties.

We’re also prepared to clarify the outside professional activities language and include the FTE definition in the contract itself.

Would you be willing to discuss this option?

Best regards, Patricia Rice, JD Vice President, Legal PeaceHealth

I read the email three times.

Arbitration. Of course. The corporate solution to all legal inconveniences: Force disputes into private arbitration where employees almost never win, where precedent doesn’t apply, where proceedings are secret, and where the arbitrators are often repeat players who know they’ll only get hired again if they rule favorably for corporations.

This wasn’t a compromise. This was a cage labeled “Alternative Dispute Resolution.”

I called N.

“They’re offering arbitration,” I told him.

“Of course they are.”

“Is this better or worse than the original language?”

“Worse. Way worse. Litigation is public. Arbitration is private. Litigation creates precedent. Arbitration dies with the case. Litigation can lead to class actions. Arbitration isolates claims. And most importantly: In litigation, there’s a judge who has to follow the law. In arbitration, there’s an arbitrator who has to keep getting hired.”

“So it’s a trap.”

“It’s a trap.”

“What do I say?”

“You tell them no. You tell them that forcing arbitration while maintaining one-sided fee provisions is exactly the kind of thing that would make a good antitrust case even better, because it shows they’re not just using monopoly power to exclude competitors—they’re using contract terms to insulate themselves from legal accountability.”

“Will that work?”

“Probably not. But at least they’ll know you’re not stupid.”

I drafted my response:

Patricia,

Thank you for reaching out.

Unfortunately, mandatory arbitration is not an acceptable alternative to fair fee provisions. Arbitration disproportionately favors employers, particularly when combined with one-sided cost structures. It also prevents the kind of transparency and precedent-setting that protects other physicians from similar situations.

I’m not asking for special treatment. I’m asking for mutual protection: If either party brings a frivolous claim, they should bear the other’s legal costs. This protects both of us.

If PeaceHealth is unwilling to agree to truly mutual terms, then we don’t have a basis for an employment relationship.

Respectfully, Dr. TooToo Medvalli

I sent it.

And then I called a moving company to cancel our Ketchikan plans.

Chapter 10: The View From Gravina Island (Reprise)

Which brings us back to where this story started: Me, on a houseboat, off Gravina Island, watching cruise ships go by.

Except I’m not actually on the houseboat. That was the other Dr. TooToo Medvalli—the gastroenterologist from a previous story, a previous battle with PeaceHealth, a previous lesson about how healthcare systems eat physicians alive.

I’m in California. In my apartment. With my family. Having walked away from PeaceHealth before they could destroy me the way they’ve destroyed countless other physicians.

But I might as well be on that houseboat. Because the isolation is the same. The understanding that I dodged a bullet is the same. The knowledge that thousands of other physicians are exactly where I almost was—trapped in systems that treat them as resources to exploit rather than professionals to respect—that’s the same too.

Let me tell you what happened after I walked away.

Sandra Koch sent me a perfunctory email: “We’re sorry we couldn’t reach an agreement. We wish you well in your future endeavors.”

Mupeet disappeared entirely. No response to my final email. No acknowledgment of the months we’d spent negotiating.

Dr. Leigh mysteriously lost his position and was never heard from again.

But here’s the thing: Three weeks after I walked away, I got a LinkedIn message from another physician. Dr. Jennifer Parks. An internist who’d been recruited by PeaceHealth for their Bellingham hospital.

Dr. Medvalli,

I heard through the medical grapevine that you walked away from a PeaceHealth position. I’m currently negotiating with them and running into similar contract issues. Would you be willing to talk?

—Jennifer

I called her.

Turns out, she was being told the exact same things I’d been told:

“Standard contract for all 1,300 physicians”
“We can’t modify the attorney fee language”
“The start date is flexible, trust us, but we can’t put it in writing”
“Everyone signs this, it’s fine”

She asked me what I thought she should do.

“Walk away,” I said. “Unless you’re comfortable being at the mercy of an organization that’s been successfully sued for antitrust violations, wage theft, and charity care fraud. Unless you’re okay with signing a contract that says they can take you to court and stick you with the bill even if you win. Unless you like the idea of having hospital privileges tied to employment with no alternative.”

“But they need doctors. I’m a good doctor. Doesn’t that count for something?”

Oh, you sweet summer child.

“No,” I said. “It doesn’t. They’ll take your labor. They’ll take your expertise. They’ll take everything you give them. And when it’s inconvenient, they’ll dispose of you. Because you’re not a physician to them. You’re a widget in a machine. A revenue-generating unit. And widgets are replaceable.”

She thanked me for my honesty.

Two weeks later, she emailed me: She’d taken a position at a smaller independent practice in Oregon. Less prestige. Less money. Better contract. Actual respect.

Good for her.

EPILOGUE: The Thing About Bags

The phrase “holding the bag” comes from an old con game. The mark is convinced to hold a bag supposedly containing something valuable. The con artists disappear. The mark opens the bag. It’s empty. They’re left holding nothing—except blame.

Corporate healthcare is the same con, except more elaborate.

They promise you meaningful work. Professional autonomy. Competitive compensation. Partnership. Respect. Family. Opportunity. All the bags are shiny and labeled beautifully.

You take the job. You sign the contract (if you’re less careful than I was). You relocate. You commit. You give them everything: your labor, your expertise, your credibility with patients, your time, your energy.

And then one day, you open the bag.

It’s empty.

Or worse: It’s full of someone else’s liability. Non-compete clauses that trap you. One-sided fee provisions that bankrupt you. Productivity metrics that burn you out. Contract language that says you’re an “independent contractor” for tax purposes but an “employee” for liability purposes. The bag is whatever they need it to be to protect themselves and screw you.

And you’re left holding it.

PeaceHealth wanted me to hold their bag.

They wanted me to:

Accept credentialing delays with no accountability
Sign a contract with one-sided fee provisions
Agree to employment as a condition for hospital privileges (antitrust violation)
Trust verbal assurances instead of written protections
Submit to mandatory arbitration
Accept “standard” treatment even when standard treatment is illegal

They wanted me to take all the risk while they kept all the power.

And when I said no, they acted shocked. Hurt, even. As if I was being unreasonable for wanting basic fairness.

This is the broken state of American healthcare: Physicians are taught to be martyrs. To sacrifice for patients. To accept poor treatment because “someone has to do this work.” To hold the bag because refusing means patients suffer.

And hospitals use that nobility against us.

They exploit our sense of duty. They weaponize our commitment to patient care. They know we’ll tolerate terrible contracts because walking away feels like abandoning patients.

But here’s what I learned: Accepting terrible contracts doesn’t help patients. It enables terrible systems.

Every physician who signs a bad contract tells hospitals they can keep offering bad contracts.

Every physician who accepts one-sided terms tells hospitals they can keep demanding one-sided terms.

Every physician who stays quiet about anticompetitive practices tells hospitals they can keep breaking the law.

We’re not helping patients by martyring ourselves. We’re helping hospitals exploit the next generation of physicians even more thoroughly.

So I didn’t take the bag.

I didn’t sign the contract.

I didn’t martyr myself on the altar of PeaceHealth’s monopoly.

And now I’m telling you this story so maybe you won’t either.

Because someone has to stop holding the bag. Someone has to say: No. This is not acceptable. This is not legal. This is not how we treat professionals.

Someone has to refuse.

So let it be us. Let it be physicians. Let it be now.

APPENDIX: What Actually Happened (The Boring But Important Legal Stuff)

Since this is a book and not just a therapeutic rant, here are the actual legal facts that underpin this story:

PeaceHealth’s Documented Antitrust Violations

Cascade Health Solutions v. PeaceHealth (2003-2008)

McKenzie-Willamette Hospital sued PeaceHealth for attempted monopolization in Lane County, Oregon
PeaceHealth used bundled pricing to exclude competitors from insurance networks
Federal jury found PeaceHealth guilty of attempted monopolization
Awarded $16.2 million in damages (trebled from $5.4 million)
Ninth Circuit vacated verdict on technical jury instruction issues, NOT on grounds that conduct was legal
Case remanded for retrial, eventually settled confidentially
Key finding: PeaceHealth has monopoly power and has used it anticompetitively

The Tying Arrangement

Legal Standard (Jefferson Parish Hospital v. Hyde, 1984): Tying is illegal when:

Two distinct products (hospital privileges + employment)
Conditioning sale of one on purchase of other
Sufficient economic power (monopoly/market dominance)
Affects substantial commerce

PeaceHealth Ketchikan:

✓ Hospital privileges and employment are distinct
✓ Sandra Koch: “All our hospitalists are PeaceHealth employed” = conditional sale
✓ Only hospital within 235 miles = geographic monopoly
✓ Physician employment market = substantial commerce

Conclusion: Prima facie tying violation

The Essential Facility Doctrine

When a facility is:

Controlled by monopolist (✓ PeaceHealth = only hospital)
Essential for competition (✓ can’t practice without privileges)
Cannot reasonably be duplicated (✓ no other hospital for 235 miles)
Access unreasonably denied (✓ tied to employment)

= Antitrust violation

What Should Happen vs. What Will Happen

What Should Happen:

Federal Trade Commission investigation of PeaceHealth’s exclusive dealing practices
Department of Justice antitrust suit for tying hospital privileges to employment
State medical board investigation of anticompetitive credentialing practices
Class action by excluded physicians for damages
Contract reform requiring mutual fee provisions

What Will Happen:

Probably nothing
PeaceHealth will keep doing this
Physicians will keep accepting it
Patients will keep suffering the consequences of reduced competition
Another hospital system will read this story and think “Great idea! Let’s tie privileges to employment too!”

Why Nothing Will Happen

Regulatory Capture: Hospital lobbyists have more power than physician advocacy groups
Isolated Victims: Each excluded physician is alone; class actions are hard to organize
Career Consequences: Physicians who sue become unemployable
Information Asymmetry: Most physicians don’t know their rights under antitrust law
Cost of Litigation: Antitrust cases cost millions; most physicians can’t afford them

What You Can Do

If you’re a physician facing similar situations:

Document Everything: Every email, every phone call, every broken promise
Get Legal Advice Early: Before signing anything
Talk to Other Physicians: You’re not alone; compare notes
Report to Regulators: File complaints with FTC, DOJ, state AG
Go Public: Stories like this one matter; silence enables abuse
Walk Away If Necessary: No job is worth sacrificing your legal rights

If you’re a patient:

Ask Questions: Why is there only one hospital system? Why no independent physicians?
Support Competition: Advocate for policies that reduce healthcare monopolies
Report Problems: If care suffers due to lack of competition, tell regulators

If you’re a regulator reading this:

Do your job: PeaceHealth has been sued successfully for anticompetitive conduct before. This is a pattern. Investigate them.

AUTHOR’S NOTE

The true author reserves his right to self-expression under the First Amendment. The author has direct knowledge of the events descried, has documented evidence supporting the narrative, and is raising concerns about anticompetitive practices in healthcare employment that affect patient care and physician welfare.

Four months of sham contract “negotiation” left me with a lot of content while consuming a lot my time and leaving me empty-handed from a job seeker’s perspective. So, this has been an interesting experiment in generating a satirical work using a corpus of factual information – more importantly, to further a cause that resonates with my heart.

Corporate healthcare serves everyone except patients and physicians. The right of independent physicians to exist should be protected. Starting a private practice nowadays is exceptionally difficult and would not be possible without an opportunity to build one’s own patient base organically. In practice, this means being on an ED call schedule, which traditionally allowed enterprising doctors to do their best for their patients, give them their business card, and try to earn their trust as a new clinic patient once they’ve recovered and left the hospital. This traditional practice gave doctors a reason to do their best for their patients in an era when patients had far greater choice of where to receive healthcare.

Excluding a physician from an ED call schedule while agreeing to grant them nominal hospital privileges, as PeaceHealth does, has proven to be highly effective at eliminating any and all competition to PeaceHealth. There should be legislation protecting physicians against such anti-competitive practices by protecting independent physicians’ ability to grow a private practice.

Some dialogue has been reconstructed from memory and notes, but the substance is accurate. Email excerpts are verbatim from actual correspondence.

The legal analysis is based on actual case law. If you think I’m exaggerating PeaceHealth’s antitrust problems, I encourage you to look up Cascade Health Solutions v. PeaceHealth yourself. It’s public record. Read the court opinions. Read the jury verdict. Read what the judges actually said about PeaceHealth’s conduct.

Then ask yourself: Why is this organization still doing this?

And more importantly: Why are we letting them?

THE END

No physicians were harmed in the making of this book. Some were saved from harm by not signing terrible contracts. That’s the point.

Acknowledgments

To my parents, who worked hard to start and operate a successful independent medical practice that has survived through decades despite corporate healthcare.

To N, who taught me that the law does not have a remedy for every malady, and for always sharing wisdom, even when it takes me time to absorb it.

To the physicians who shared their own PeaceHealth insights and confirmed I wasn’t crazy.

To David Sedaris, whose writing showed me that humor and horror can coexist, and that sometimes the best way to process trauma is to laugh at its absurdity.

To my family, who supported me through four months of employment limbo and didn’t complain (much) when I walked away from a high-paying job on principle.

And to every physician reading this who’s wondering whether they should sign that contract, accept that job, take that chance:

Trust your gut. Read the fine print. Get a lawyer. And remember: No bag is worth holding if it’s full of someone else’s bullshit.

Published by Reality Press “Where the truth hurts, but at least it’s funny”

For more information: FTC Complaint Hotline: 1-877-FTC-HELP DOJ Antitrust Division: antitrust.complaints@usdoj.gov Healthcare Whistleblower Resources: http://www.whistleblowers.gov

If you’re a physician with a similar corporate healthcare story, you’re not alone. Correspondences can be directed to Oskar Rausch (oskar.rausch@proton.me), a researcher at the Make America Constitutional Again Institute (MACAI) in San Juan, Puerto Rico.

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