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.

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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

NYC Captives

Notes from a two-day detour, and a brief field guide to the collapse

By Omar Nabil Metwally, MD

Written and published from a plane with its engines turned off on the runway, and no ETA.

“This is real. I am really here.”

— Gate B33, John F. Kennedy Airport

The Cast

The Bulbul my father. A physician. Dreams of a home by the water.

Mom (Louly) awake since 6am, on the phone since midnight.

Me the son. The reason for the trip.

Siblings the chorus, texting from a safe distance.

Part One

The Detour

In which a family goes to New York for a piece of paper.

I

The Errand

We came to New York for a piece of paper. Military exemption paperwork, to be filed at the Egyptian consulate, in person, because some things still require a body in a room.

The consulate visit was brief and uncomplicated. That is the last sentence in this story that will be either of those things.

II

The Logic of a Physician

Before the consulate visit, I enjoyed kombucha at a cafe across the street. On the back of the can, a founder’s story: an infectious disease physician who met his wife on his way to the West African Ebola outbreak, and who now brews wellness without compromise.

Bulbul: What a wasted career. Kombucha is bland without the spice of pain.

⸻

Bulbul didn’t actually speak the above words. I am paraphrasing and synthesizing decades of wisdom that he’s instilled in me. Mom asked if I wanted milk in my cappuccino. Mom has not slept in a long time. Neither have I. It reminds me of how she used to order steak at Red Robin: well done but not too dry, medium well without the pink.

Bulbul says he’s always dreamed of a home by the water. I tell him I want to live in the mountains.

He suggests Tennessee. I ask him why Tennessee. If he’s ever been to Tennessee.

He says no. But I hear it’s gorgeous.

“Where then, if not Tennessee?” he asks. “Arkansas?”

And slowly I began understanding the logic of this man. My father. The logic of a physician.

That’s the thing about doctors. Too naive.

Later, on the way in, Bulbul slipped and called the consulate the pharmacy. He has not slept in a long time. Neither have I. I silently hope he wouldn’t walk inside asking for controlled substances.

III

The Cancellation

Then Delta began its slow work. A delay, and another, and another after that, each one announced with the confidence of a thing that would not happen again. At 2am the flight was cancelled outright. The ground staff had no information, no plan, and no visible theory of what an airline is for.

Mom had a system shutdown with her eyes open, holding the iPhone to her head with one hand, gazing at a crowd of angry Delta passengers trying to grasp what was happening to them.

By morning, Mom and Dad were still trying to find a flight to DTW. I was in a Lyft on the way to JFK.

NYC captives.

⸻

In a desperate act of love for one’s child, Mom bought the last ticket to Detroit, sacrificing herself and the Bulbul for their son.

And so they set out on their new life in Chinatown, wondering if they’ll ever see their children again. If anyone will remember.

IV

That’s Your Bed. This Is Mine.

Poor Mom. She was beyond exhausted last night. We had a really sweet Bengali Lyft driver, and Mom fell asleep listening to me talk to her.

The hotel — a nice and expensive SoHo hotel, for the record — is where Mom’s discomfort became obvious. She asked if there are bed bugs here.

The Bulbul asked with sincere concern: “What are you afraid of, rapists?”

And for a moment, I wondered if I should be afraid too. But I was too tired. I simply told the Bulbul, waving at Mom’s bed: “That’s your bed. This is mine.”

Sibling T: “Mom’s worst nightmare.” · Sibling U: “I told her to sleep at my place tonight.” · Me: “I told her the same.”

V

Morning in Chinatown

The Bulbul woke up at 10am, scratched his balls, and went back to sleep. Louly had been awake since 6am and on the phone since midnight.

I walk through vibrant, endlessly fascinating Chinatown — open air markets, tai chi in the park, the sounds, scents, and colors of life — and have coffee at a Vietnamese cafe. Between a Grab bike helmet and condensed milk cans, a hardcover book commands my attention: KIM JONG IL LOOKING AT THINGS. The Supreme Leader in a field of green wheat, generals arranged behind him like a hedge, all of them looking at things.

I flip through it while waiting for my coffee. It seemed like the correct souvenir from a week in which nobody in charge of anything was looking at anything.

Seriously though, Chinatown is endlessly fascinating. The mental stimulation was almost worth the pain.

⸻

VI

To the South

And now I am listening to the undulating breaths of the peaceful young Korean man taking me to freedom.

To the south. Where I am free to try, and to fail, and to keep trying.

VII

Gate B33, Terminal 4, John F. Kennedy Airport

This is real. I am really here.

Look closely and you’ll see a young woman with a travel pillow hugging her neck. She is crying. Not tears of sadness or fear — that was hours ago. These are tears of joy and relief.

And just out of view, to my right, is a veiled Arab woman wearing sunglasses and munching potato chips. She has witnessed true hardship in her life. Her family has lost everything, twice, and started over three times. To her, it’s another beautiful day in NYC, and yesterday’s detour an almost imperceptible inconvenience.

The paperwork, by the way, went through without a problem. It was the only institution all week that did what it said it would do, and it belonged to another country.

Part Two

The Failed State

In which the delay turns out not to be about Delta.

VIII

Not Enough Human Workers

For thirty-six hours I believed this was a Delta problem — a private failure, the kind you can be compensated for with a voucher. Then the article came through the chat.

Air traffic controllers had called out sick in unusual numbers. Thunderstorms did the rest. Equipment failed at a few hubs, apparently on principle. The FAA answered with ground stops at eight major Northeast airports, and the Transportation Secretary went on television to advise the nation to brace for more of the same, in the tone of a man reporting the weather rather than the forecast he himself commissioned.

The fix is on the books: 8,900 new controllers, hired by 2028. A promise scheduled to arrive several years after the problem — the national genre, really. In the meantime the system is short a few thousand people and runs on mandatory overtime, six-day weeks, and the private decency of individuals who have been given no other tools.

ATC staffing issue. There’s literally not enough human workers to safely direct air traffic.

⸻

That sentence should stop a country cold. It didn’t. It scrolled past between a sports score and an ad.

This is what a failed state looks like in a rich country. Not rubble. Not sirens. A terminal at 2am, fully lit, air-conditioned, staffed by people in uniform who have been instructed to know nothing, while four hundred citizens refresh an app that has also been instructed to know nothing. The infrastructure is immaculate. The thing it was built to do has quietly stopped happening.

They turned the engine off.

IX

The Marinade

By hour six a terminal stops being a place you pass through and becomes a room you live in. The lighting does not dim. The chairs are bolted at a distance calculated to prevent sleep. There is one working outlet for every forty citizens, and the man who found it first is now a landlord.

A gate agent has been issued a script containing four sentences, none of which contain information. A man in a wedding suit is explaining to her that the wedding is his. A woman with three children under six is being told that the hotel voucher system is experiencing high volume. Somewhere a screen updates DELAYED to DELAYED, which is a design achievement nobody has yet been fired for.

Around 1am the tone changes. It is not really a decision anyone makes. A phone gets thrown. Somebody climbs onto the counter to address the crowd, as if the crowd were the problem. A bank of chairs goes over. Four hundred adults who have been standing in a line for nine hours discover that the line was the only thing holding them.

And then the police — who, unlike the airline, are never understaffed. They arrive fast, in numbers, kitted out, radios working, systems online, budget intact. They have no flights either. What they have is authority.

Pepper spray, marinate, simmer down.

⸻

It deserves the culinary vocabulary it has earned, because that is precisely the procedure. The crowd is not dispersed; one angry passenger is arrested and made an example of— and then the room is left to rest. Coughing counts as agitation. By 3am it has simmered down to a low, even sorrow that requires no further attention from management, which was always the desired doneness.

Note the division of labor. The country could not find enough people to safely direct airplanes. It found thirty of them in eleven minutes to help the passengers simmer down. This is not incompetence — incompetence is random, and this is not random. This is a budget. Somebody sat in a room and decided which of those two capacities the republic would keep funded, and they were not confused about it, and they were correct about what they would need.

Terminal Braise

Serves 400. Total time: 9 hours, plus resting.

400 travelers Room temperature. Do not let them settle; bolt the seating so it cannot be reclined.
1 cancelled flight Announced at 2am, off-menu, no substitutions.
4 gate agents Deboned of all information. Keep visible — they absorb the heat.
Fluorescent light Full, continuous, no dimmer. Prevents the mixture from setting.
1 outlet per 40 guests For tension. Encourages the crowd to season itself.
Capsaicin, to taste Applied as a fine mist, evenly, without regard to which portions were already tender.
Method Delay. Reduce. Agitate. Season generously. Rest until quiet. Serve at 6am to a connecting flight that has also been cancelled.

X

A Modest Proposal, Aviation Edition

I wondered aloud in the chat what would happen if healthcare workers used this strategy.

The answer, I think, is nothing. Nothing visible. That is precisely the problem, and it is the difference between the two collapses.

When aviation fails, it fails all at once and in public. Eight airports go dark on a map. Cancellations aggregate into a number a news desk can put in a headline. A cabinet secretary must appear on a Sunday program and say a sentence. The failure has a shape, a location, and a spokesman.

When healthcare fails, it fails one person at a time, in private, at a pace slow enough to be mistaken for normal life. Nobody issues a ground stop. There is no board of red CANCELLED beside every name. There is a voicemail about prior authorization. There is a first available appointment in March. There is the 6th bill that arrives twelve months later, itemized in a language invented specifically so that it cannot be disputed. There is a man in a parking lot rationing an injection because the alternative is his daughter’s tuition.

The Bulbul has practiced medicine for decades. He has never once been able to call in sick in a way the country would feel. Nobody would ground a single flight. The delay would simply be distributed — to a waiting room, to a hallway bed, to a phone tree, to the exhausted — which is where it has been distributed the entire time.

The system does not lack a plan. Distributing the failure onto individuals is the plan.

⸻

XI

The DIY Healthcare Kit

So the market has done what markets do when a public good stops arriving. It has packaged the absence and sold it back, at retail, with free shipping over $35.

What follows is the standard household kit as currently assembled by roughly everyone I know. Contents may vary by state, by employer, and by whether your father is a physician.

Contents of the Kit

One (1) laminated card Reads: HAVE YOU TRIED DRINKING WATER AND GETTING MORE SLEEP. Doubles as an ice scraper.
Search engine, unlimited For self-diagnosis. Every symptom resolves to either dehydration or something with a five-year survival rate. There is no third result.
Chatbot triage, free tier Twenty messages a day. Endlessly patient, faintly hedging, available at 3am — which is more than can be said for the on-call line, and it does not bill you.
Veterinary-grade supplies Sutures, saline, antibiotics labeled FOR AQUARIUM USE ONLY. The fish are, notably, not asked for a copay.
Prior authorization dice Roll for coverage. On a 1, the medication your physician selected is denied by someone who has not attended medical school and will not be identified.
A friend who is a nurse Not included. Must be sourced independently. Answers texts at all hours, unpaid, and is the actual load-bearing element of this kit.
One (1) GoFundMe template Pre-filled. Optimized for the photograph in which you still look well. A stranger’s pity, priced at a 2.9% processing fee, is now a recognized payer.
Insulin, one vial Financed over thirty-six months. Also available same-day, six hours south, in a country the kit does not name.
Blood pressure cuff, imported Ships from Shenzhen in nine days. The one in the clinic came from the same warehouse. Yours cost less.
A physician father, if available The Bulbul model. Diagnoses by WhatsApp, opinions unlimited, second opinions free, has never billed a member of his own family or, judging by his lifestyle, most of yours.
Meal voucher, $15 Valid only at a terminal restaurant that closed in 2019. Included for continuity with the aviation module.

This kit is not a substitute for medical care. Neither, increasingly, is medical care. Some assembly required; all assembly required; you are the assembly.

XII

Coda, Gate B33

So: a family stranded overnight by an air traffic system that has run out of people, in a country that will hire them in two years, in an airport whose staff were forbidden the dignity of an explanation and whose only fully funded service arrived at 1am with a canister. A woman crying with relief because a plane exists. A woman eating potato chips who has calibrated hardship against an actual war and finds this an almost imperceptible inconvenience. Both of them are right. That is the strangest part.

You can be a captive of a failing system and still be the luckiest person in the terminal. Both things run on the same track. Empire ends the way our flight ended — not with a bang, but with a gate agent who does not have the information, and a crowd that has learned not to ask twice.

And still: to the Midwest. Where I am free to try, and to fail, and to keep trying — which, when the machinery stops, is the entire remaining infrastructure, and which is why we came for the piece of paper in the first place.

The consulate visit was brief and uncomplicated.

Posted on by omarmetwally

Blue Jeans

By Omar Metwally, MD

August 4th 2021

This is a photo of Salt Lake City, Utah on April 3rd, 2020.

At the end of March 2020, I drove from the San Francisco Bay Area, my home of eight years, back to my home state of Michigan to volunteer in medical units overflowing with patients who were sick with the novel coronavirus. My puppy and my few personal belongings, which had consolidated over the years after frequent moves from one city apartment to the next, are packed into my Honda Civic, the rest of my belongings left behind in an apartment I quickly fled to avoid state border closures. Every fleck of my skin, from my face and lips to my toes, is swollen, red, and painful — a farewell gift from a patch of poison oak that my puppy discovered during one of our last hikes through the East Bay’s eucalyptus forests. I am on fire.

I drove from California to Michigan via interstate highways that traverse the heart of America with prescriptions for steroids to treat my case of fulminant poison oak hypersensitivity and an aloe plant on my lap. As I spent the better part of four days behind the wheel cutting off aloe leaves[1] and rubbing them on my skin to relieve the intense burning that pushed me to the limits of patience, I reflected on how quickly life had changed in such a short period of time: the perpetual line of masked people in front of the deli where I used to walk a block over to pick up a sandwich for lunch and carry home fresh produce; the panic of trying to hunt down dog food after all the local pet stores shuttered their doors indefinitely; driving an hour and a half to Sonoma County in pursuit of milk; the tense, heavy atmosphere at my hospital as it filled up with seriously ill patients – and the limited therapeutic options doctors had at their disposal at the start of the pandemic.

Many people lost their lives and their livelihoods during the pandemic, which continues to take its toll around the world.

This is a photo of Salt Lake City, which I did not take because it wasn’t how I wanted to remember the capital of one of the most beautiful states in America.

After a few hours rest in a nearly-deserted hotel, I wake to continue our journey east. Except for a police patrol and a homeless man, there isn’t a soul on the streets of downtown Salt Lake City, as I walk my dog in search of a cup of coffee. This is not how a city should ever look, except in Cormac McCarthy’sThe Road. Even the national coffee chains one could previously count on were closed, and I resorted to brewing my daily cup of joe on the side of the road with the aid of a propane-powered camping stove.

Michigan was hit early and hard by the COVID-19 pandemic, but finding food for puppy and milk for me was still easier outside of California’s dense urban areas. When the State of California issued the first stay-at-home order in March 2020, it felt like standing on a beach watching tsunami waves roll toward land. While those tsunami waves are just now making landfall in certain countries that managed to dodge the first pandemic wave by means of fast, coordinated action, the aftershocks are being felt acutely by all. Personal loss and economic damage on such a large scale will take time to heal. The cost of basic provisions, from groceries to building materials, has increased markedly in just a few months, and the future is more uncertain now than it was in the pre-pandemic world.

Despite the great difficulty of finding a sewing machine and fabric in the spring of 2020, I managed to purchase my first sewing machine and learned to sew face masks with the help of a tutorial on the CDC’s website. The linen masks I created were far more comfortable and breathable than surgical masks, and I felt empowered to create something that had become as indispensable to daily life as a smart phone, especially at a time when masks were expensive and hard to come by. Just a few months before moving back to Michigan, I was taking my shorts to alterations shops to replace buttons, and I would have never imagined operating a sewing machine myself.

Learning how to sew gave me the knowledge and skills to harness an ancient technology – textiles – to create functional and beautiful things that can’t be made using 3D printers. After using the remaining linen to sew window drapes for our home, my next challenge was denim. A pair of jeans is both a tool and a lasting work of art. Subject to areas of extremely high tensile forces, jeans hold things together to keep us warm while serving as a physical barrier between our bodies and the world. Denim adapts to the shape of our bodies over time, and we hardly notice a comfortable, well-fitting pair of jeans as we go about our business. Jeans have front and back pockets to hold our keys, phones and wallets, and jeans take on a uniquely cool look with each wash, tear, fray and stain.

U.S. Patent Number 139,121 (“Improvement in fastening pocket-openings”) for using rivets to reinforce pockets awarded to Levi Strauss and Jacob Davis on May 20th, 1873.
Source: https://patents.google.com/patent/US139121A/en

Levi Strauss of San Francisco and his business partner, Jacob Davis, a tailor from Reno, Nevada, were awarded U.S. Patent Number 139,121 (“Improvement in fastening pocket-openings”) for using rivets to reinforce pockets on May 20th, 1873 [2]. There is a big difference between sewing trousers and sewing a durable garment that can withstand years of vigorous use. Strauss and Davis’ invention helped improve the longevity of jeans as a tool, a garment worn by people to help them work hard, and a garment that also happens to look nice!

As with face masks, I began sewing jeans out of necessity. Shopping for clothes to replace the wardrobe I left behind in California was impossible or extremely challenging for many months. Even before the pandemic, happening across a well-fitting pair of jeans involved visits to several outfitters and spending a day trying on jeans. If I was lucky enough to find a pair that fit, I didn’t have say in the properties of the denim I would bring home to break in: the fabric color, weight, style and stretch.

Jeans have become staples in apparel and are worn by people of every rank and file all over the world. The mass production methods necessary to achieve the current market prices rely on the sweat and lifeblood of factory workers who specialize in one small step in a complex process overseen by the proprietor. What surprised me most about learning how to sew jeans was the remarkable fine motor skills and intensity of labor which the process entails. With my wife’s help, we can together create a pair of jeans in three days: one day to take measurements, draft a pattern, cut fabric and serge the pieces; another day to sew the pieces; and a third day to add trimmings and hem. The price tags on store-bought jeans betray the immense skill and effort involved in creating a pair of shiny new blue jeans, but there is no price on the joy of achievement.

Whether I’m rounding in the hospital or under the hood of my car, I enjoy wearing a pair of hand-sewn jeans as a reminder that sewing jeans, like the practice of medicine, requires both knowledge and skill, a fruitful marriage of theory and practice. Creating a well-fitting pair of jeans requires a good grasp of human anatomy and the theory of pattern design. It requires an appreciation for how movement – walking, running, sitting and squatting – impart forces on the fabric, and how manufacturing techniques can reinforce these high-stress areas. Sewing jeans also requires appreciation for how denim is woven and dyed, and how its properties can be modulated to yield a certain feel and look. The theory of jeans-making must be combined with outstanding sewing skills to produce an awesome pair of jeans. Learning to work with a heavy fabric like denim takes a lot of practice and patience.

Even if I had an endlessly long list of customers, a mom-and-pop jeans shop operating in the United States cannot compete head-to-head with a jeans factory that outsources its operations to places where the cost of labor is significantly lower. And while I can’t pretend to be an expert seamster as far as sewing jeans is concerned, practice makes perfect.

A pair of custom Ox Jeans made using a computer program that algorithmically generates jeans sewing patterns from a handful of body measurements

My offering:

  • Custom, algorithmically-generated jeans sewing pattern. Includes:
    • Full-size printout containing all pieces for a custom-sized pair of jeans, based on your body measurements
    • 3 business day turn-around
    • Cost: $50
  • A custom-tailored pair of jeans. Includes:
    • Hand-sewn pair of jeans made with 100% American denim
    • Constructed using the algorithmically-generated sewing pattern (above)
    • Cost: $600

A pattern can be purchased separately from the jeans so that people with sewing skills can create their own jeans at home.

To purchase a custom jeans pattern and/or a pair of custom-tailored jeans, request an order form by emailing me (omar@oxjeans.me) with “Ox Jeans Order Form” in the subject line.

References

  1. Aloe vera: a review of toxicity and adverse clinical effects. Guo X and Mei N. J Environ Sci Health C Environ Carcinog Ecotoxicol Rev. 2016 Apr 2; 34(2): 77–96. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6349368/
  2. U.S. Patent Number 139,121. “Improvement in fastening pocket-openings.” Jacob Davis of Reno, NV, and Levis Strauss & Company of San Francisco, CA.