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The Last Free Doctor in America

The Last Free Doctor in America

He refused to sign away his constitutional rights. Then he refused to participate in modern life at all.

By Oskar Rausch

November 28, 2025

The houseboat bobs gently in Lake Huron, anchored about 200 yards off a small, nameless island in Michigan’s Thumb region. There is no dock. Visitors must hire a boat from the mainland, navigate past a half-submerged buoy, and announce themselves by shouting. A German Shepherd named Kai will bark—not aggressively, just to establish that someone is paying attention.

Dr. TooToo Medvalli, MD, will emerge from the cabin wearing a flannel shirt with a laminated pocket Constitution visible in the breast pocket. He is 61 years old, board-certified in gastroenterology, and has not practiced medicine in 18 years. He has not had a cell phone in 18 years. He has not used the internet, held a credit card, or maintained a bank account in 18 years.

He has, however, preserved every single one of his Seventh Amendment rights.

“I am aware,” he tells me, settling into a camp chair on the deck, “that this makes me sound insane.”

The numbers are not in dispute. Employees who must resolve workplace disputes through mandatory arbitration win only 21.4 percent of their cases, compared with 36.4 percent in federal court. When they do prevail, their median award of $36,500 represents barely one-fifth of the $176,426 median in court. Perhaps most troubling, researchers estimate that 98 percent of potential employment claims simply vanish—never filed because the system is designed to make pursuing them economically irrational.

These statistics come from Professor Alexander J.S. Colvin of Cornell University, whose research on employment arbitration is the most comprehensive in the field. Professor Cynthia Estlund of NYU Law School has documented what she calls “the black hole of mandatory arbitration”—the phenomenon whereby more than 60 million American workers are subject to mandatory arbitration, yet only about 2,500 employment arbitration cases are filed each year. That’s one claim for every 10,400 covered workers.

The legal scholars have a term for agreements that consumers and employees must accept without negotiation: contracts of adhesion. Sign or don’t get the job. Sign or don’t open the bank account. Sign or don’t use the cell phone.

TooToo Medvalli chose “don’t.”

To understand how a gastroenterologist ended up living on a houseboat in Lake Huron, communicating exclusively through the United States Postal Service, you have to understand that TooToo Medvalli has never done anything halfway.

He was born in 1986 in Hamtramck, Michigan, to Hungarian immigrant parents who emphasized education with the intensity common to families who had sacrificed everything to provide it. He graduated from the University of Michigan, attended the University of Michigan Medical School, completed his internal medicine residency at UCSF, and finished a gastroenterology fellowship at Stanford. By 2018, at age 32, he was a board-certified gastroenterologist with offers from three major health systems.

He was also, by his own description, “constitutionally incapable of not reading things.”

“My colleagues would get these contracts—60, 70 pages—and they’d flip to the salary section, maybe glance at the benefits, and sign,” Medvalli says. “I read every word. Every clause. Every definition in the appendix.”

It was in one of these appendices that he first encountered a mandatory arbitration clause.

“I remember the exact moment,” he says. “Page 47. ‘Any dispute arising out of or relating to this Agreement shall be resolved exclusively through binding arbitration.’ I didn’t even know what that meant. So I looked it up.”

What he found changed the trajectory of his life.

The Federal Arbitration Act of 1925 was drafted by Julius Henry Cohen, a Progressive-era lawyer, and championed by the New York Chamber of Commerce for a specific, limited purpose: enabling merchants of relatively equal bargaining power to resolve disputes efficiently outside congested courts. The drafters repeatedly assured legislators that the Act would not apply to employment contracts or adhesion contracts. Section 1 explicitly exempts “contracts of employment of seamen, railroad employees, or any other class of workers engaged in foreign or interstate commerce.”

The Supreme Court has spent the past four decades systematically transforming this narrow procedural statute into something its drafters would not recognize.

Southland Corp. v. Keating (1984) held that the FAA applies in state courts and preempts conflicting state laws—despite legislative history clearly indicating Congress viewed the FAA as purely procedural. Circuit City Stores v. Adams (2001) narrowed the employment exemption to cover only transportation workers, extending FAA coverage to virtually all employment contracts. AT&T Mobility v. Concepcion (2011) held that the FAA preempts state unconscionability doctrines that would invalidate class action waivers. Epic Systems Corp. v. Lewis (2018) ruled that employers can use individual arbitration agreements to prevent collective action even for wage and hour claims.

Justice Ruth Bader Ginsburg read her dissent in Epic Systems from the bench—a rare act of judicial protest. She called for congressional correction of the Court’s “elevation of the FAA over workers’ rights.”

Congress has not corrected it.

“I went to HR,” Medvalli recalls, “and I said, ‘I can’t sign this.’ They looked at me like I’d grown a second head.”

He explained his concerns: the elimination of jury trial rights, the restriction of discovery, the repeat-player advantage that research showed systematically favored employers, the class action waiver that would prevent workers from banding together to challenge systematic violations.

The HR representative listened politely. Then she said, “It’s standard. Everyone signs it.”

“That’s not a legal argument,” Medvalli replied. “That’s a description of capitulation.”

He was not hired.

Over the next six months, Medvalli applied to 47 different healthcare organizations. Every single one required mandatory arbitration as a condition of employment. Every single one told him it was “standard.”

“I started keeping a tally on my pocket Constitution,” he says, pulling out the document—laminated now, worn at the edges. Small hash marks cover the inside back cover. “Forty-seven rejections. All for the same reason. I wasn’t refusing to work. I wasn’t asking for more money. I was just asking to retain access to the legal system that the Constitution guarantees.”

The question everyone asks—the question I asked, standing on his houseboat deck while Kai investigated my backpack with alarming intensity—is: Why not just sign?

Medvalli has heard this question hundreds of times. He has a speech prepared.

“In 1992, the year after the Supreme Court’s Gilmer decision permitted arbitration of federal employment discrimination claims, approximately 2 percent of American workers were subject to mandatory arbitration,” he says, rattling off statistics with the fluency of a man who has spent 18 years alone with legal journals. “By 2017, that figure had reached 56.2 percent—more than 60 million workers. The Economic Policy Institute projected it would reach 80 percent by 2024. Eighty percent of American workers, required to surrender their constitutional rights as a condition of employment.”

He pauses.

“At what point does a right that can be forced-waived as a condition of basic economic participation stop being a right at all?”

The dog deserves his own explanation. Medvalli acquired Kai in 2026, shortly after losing his house to foreclosure. (The mortgage company’s arbitration clause had prevented him from disputing the foreclosure in court—a fact Medvalli describes as “darkly ironic.”) Kai is now 17 years old, ancient for a German Shepherd. In his younger years, he expressed his considerable psychological complexity through the systematic destruction of fabric, furniture, and infrastructure.

“He once humped a buoy so aggressively it sank,” Medvalli says, with something approaching affection. “I had to pay to have it replaced. In cash, obviously. I don’t have a bank account.”

The cascade of withdrawals happened gradually, then all at once.

First the employment contracts. Then the cell phone, after Medvalli actually read his Verizon service agreement and discovered that he’d theoretically agreed to waive his right to sue, his right to participate in class actions, and his right to a jury trial.

“I threw it in Lake Huron,” he says. “Kai looked very confused. He expected to retrieve it.”

Then the internet (arbitration clause). The credit cards (arbitration clauses). The streaming services (arbitration clauses). The bank account (arbitration clause).

“Did you know that credit card issuers representing 53 percent of all credit card debt impose arbitration?” Medvalli asks. “Affecting over 80 million consumers? The Consumer Financial Protection Bureau documented this in 2015. Ten years ago. Nothing has changed.”

He bought the houseboat in 2027, anchoring it off a small island because even the mainland marina operators had arbitration clauses in their slip rental agreements. He grows vegetables, collects rainwater, catches fish. He communicates through the U.S. Postal Service, which he notes with satisfaction has no arbitration clause.

His sister, Margaret, visits once a month to bring supplies. She has spent 18 years trying to convince him to rejoin society.

“The Founders would be proud,” Medvalli tells her.

“The Founders used corn cobs,” she replies.

He takes the toilet paper.

Word of Medvalli’s stand has spread slowly through legal academic circles. Law students write papers about him. Constitutional scholars cite him in footnotes. A documentary crew visited in 2031—arriving in an arbitration-clause-encumbered rental boat—and produced a film that premiered at Sundance to modest acclaim.

Medvalli didn’t see it. He couldn’t sign the streaming service’s terms of service.

“It made you look only moderately insane,” Margaret reported.

The film sparked a brief national conversation about forced arbitration. Op-eds were written. Senators gave speeches. The FAIR Act—the Forced Arbitration Injustice Repeal Act, which would invalidate pre-dispute arbitration agreements for employment, consumer, antitrust, and civil rights disputes—was reintroduced in Congress. A hashtag trended for nearly six hours.

Then everyone went back to clicking “I Agree” without reading.

One letter stood out from the thousands Medvalli received after the documentary. It came from Gretchen Carlson, the former Fox News anchor whose lawsuit against Roger Ailes had been complicated by her employment contract’s arbitration clause. Carlson had found a legal strategy to circumvent the clause—suing Ailes personally under New York City law—and her $20 million settlement had helped catalyze the #MeToo movement. In 2022, she’d advocated successfully for the Ending Forced Arbitration of Sexual Assault and Sexual Harassment Act, which President Biden signed into law.

“Dear Dr. Medvalli,” the letter read:

I understand your fight. When I discovered what my arbitration clause meant—that I would be forced into the secret chamber of arbitration, and nobody would ever hear from me again—it was one of the darkest days of my life.

But I chose to find a way around it, to fight within the system, to change what I could. The 2022 law that lets survivors of sexual assault and harassment choose court over arbitration—it happened because of that fight.

You’ve chosen to step outside the system entirely. I’m not sure either of us is right. But I’m not sure either of us is wrong, either.

The law I helped pass was called “the biggest labor law change in 100 years.” But it only covers sexual assault and harassment claims. Wage theft claims? Discrimination claims? Safety violations? Still arbitrated. Still disappeared.

Maybe we need both approaches—people like me fighting from inside, and people like you refusing to participate at all.

Medvalli has the letter pinned to his cabin wall, next to a handwritten sign that reads:

THEORETICAL RIGHTS: 100%

PRACTICAL PARTICIPATION IN MODERN SOCIETY: 0%

REGRETS: COMPLICATED

“I am not a model to emulate,” Medvalli says, as the sun begins to set over Lake Huron. Another cruise ship—one of the small Great Lakes tour vessels—passes in the distance. “I am a cautionary tale.”

He is quiet for a moment.

“But maybe every person who clicks ‘I Agree’ without reading should have to look at me first and ask themselves: Is this the only alternative? Is the choice really between surrendering your constitutional rights and becoming this?”

He gestures at the houseboat, the island, the dog now attempting to mount my backpack.

“If the answer is yes—if the system has been designed so that the only way to preserve your rights is to withdraw from society entirely—then at least people should know that’s the choice they’re making. At least it shouldn’t be done in ignorance, buried in fine print, invisible and unexamined.”

Kai successfully mounts the backpack. Medvalli doesn’t apologize.

“He does that,” he says.

Federal Judge William G. Young once wrote that the rise of forced arbitration represents “among the most profound shifts in our legal history. Ominously, business has a good chance of opting out of the legal system altogether and misbehaving without reproach.”

Proponents argue that arbitration is faster and cheaper than litigation. The Chamber of Commerce claims consumers win more often in arbitration and receive comparable awards. But these arguments ignore what researchers call “the denominator problem”: they examine only the tiny fraction of claims that make it to arbitration, not the 98 percent that disappear. They ignore the repeat-player advantage that systematically favors corporations. They ignore that a system designed to be fast and cheap is worthless if it deters virtually all claims from being filed.

The Seventh Amendment guarantees the right to a jury trial in civil cases. The Founders understood that this right served as a critical check on concentrated power. When corporations can compel their employees and customers to surrender this right as a condition of employment or commerce, they have effectively nullified a constitutional protection for the vast majority of Americans.

TooToo Medvalli knows all of this. He has had 18 years to read about it, think about it, write letters to congressmen about it.

None of it has changed anything.

As I motor back to the mainland, I pass the spot where the buoy used to be—the one Kai allegedly sank. The sun is setting, painting Lake Huron in shades of orange and pink. It is, objectively, beautiful.

My phone buzzes. A notification from my bank: updated terms of service. Would I like to review them?

I think about Medvalli, alone on his houseboat, communicating through letters, preserving his theoretical rights while the world clicks “I Agree” around him.

I think about the 60 million workers bound by arbitration clauses. The 300 million telecom subscribers. The 80 million credit card holders. The 98 percent of claims that simply vanish.

I think about whether rights that can be forced-waived are really rights at all.

Then I click “I Agree” without reading.

I have a mortgage to pay.

Oskar Rausch is a researcher at the Make America Constitutional Again Institute (MACAI) in San Juan, Puerto Rico. He can be contacted at oskar.rausch@proton.me

Editor’s Note

The statistics cited in this article are drawn from peer-reviewed research, including:

  • Alexander J.S. Colvin, “An Empirical Study of Employment Arbitration,” Journal of Empirical Legal Studies (2011)
  • Cynthia Estlund, “The Black Hole of Mandatory Arbitration,” North Carolina Law Review (2018)
  • Katherine V.W. Stone & Alexander J.S. Colvin, “The Arbitration Epidemic,” Economic Policy Institute (2015)
  • Consumer Financial Protection Bureau, “Arbitration Study: Report to Congress” (2015)

Dr. TooToo Medvalli is a fictional character who first appeared in “Cruise Ship Doctor” (2025). This article is a work of satirical fiction. All constitutional principles cited are real. All absurdity is intentional.

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Cruise Ship Doctor

Cruise Ship Doctor Cover

Dr. TooToo Medvalli, MD stood on the deck of his newly purchased houseboat and watched the cruise ships glide past. They moved like fat white geese across Tongass Narrows, their passengers waving at the picturesque Alaskan landscape, oblivious to the small brown man who waved back from his floating prison.

The houseboat had cost him his entire signing bonus plus half his relocation package. It was anchored off Gravina Island because even the marina operators in Ketchikan proper had refused his business. Word traveled fast in a town of eight thousand souls.

Dr. Medvalli is not welcome here.

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

TooToo had wanted to point out that it was a clear day with calm seas and he weighed 165 pounds, but there seemed little point in arguing meteorology with a ferry operator who was pretending to check a computer screen that was clearly showing a screensaver of bald eagles.

It was remarkable, really, how a community could mobilize against one Marxist gastroenterologist who’d had the audacity to win a years-long legal battle for hospital privileges. He’d seen less organized responses to actual public health emergencies.

TooToo checked his phone. No service, of course. The signal barely reached Gravina. He’d have to row his dingy across the narrows just to send an email, and even then, he’d need to do it from the parking lot of the medical center—the building where he now, legally, had the right to practice.

The right, he thought grimly, pulling his coat tighter against the October wind. Just not the ability.

His first day of hospital privileges had been three weeks ago. He’d rowed across the narrows at dawn, tied up his dingy, and walked the mile and a half to PeaceHealth Ketchikan Medical Center. His white coat was crisp, his badge freshly laminated, his credentials irrefutable.

Behind the nurses’ station, he heard it immediately: He is the doctor. Whispered like a curse. Not his name, never his name. Just the definite article and the profession, as if there were only one doctor in all of Ketchikan and he was it—a distinction that would have been flattering if it weren’t spoken in the same tone usually reserved for announcing a sewage backup.

The nursing staff had looked through him as though he were made of glass.

“Dr. Medvalli,” he’d introduced himself to the charge nurse. “I’m here to see my first patient.”

“You don’t have any patients, Doctor.”

“I’m on the hospitalist roster. I should have been assigned—”

“The roster is full today.”

“I can see the board from here. There are three patients without—”

“Dr. Roz is covering those.”

“Dr. Roz is already covering six patients. That’s why I’m—”

“Have a nice day, Doctor.”

That had been the template. Polite. Professional. Absolute.

TooToo had learned during his residency to recognize institutional resistance. At UCSF, it had been overt—the old guard protecting their territory, the pecking order enforced through public humiliation and impossible call schedules. Here in Ketchikan, it was different. No one raised their voice. No one wrote him up. They simply… didn’t need him.

Which was fascinating, really, considering they’d been advertising for hospitalists nationally for two years. Apparently what they needed was hospitalists who hadn’t committed the cardinal sin of believing that winning a lawsuit meant winning anything at all.

Patients requested other doctors. Referrals went elsewhere. His clinic appointments, carefully blocked out in the system, remained empty.

The boycott extended even to the mundane. The hospital cafeteria claimed their register was broken when he tried to buy lunch. The staff bathroom was always occupied when he approached. His locker, freshly assigned after months of legal wrangling, was in the old wing—the one where they stored broken equipment and outdated files.

TooToo had briefly considered requesting a locker upgrade, but decided against it. There was something poetically appropriate about storing his personal belongings next to a defibrillator from 1987 and a box labeled “OLD CHARTS DO NOT DESTROY (YET).”

On his houseboat, TooToo opened a can of beans he’d brought from Michigan. His stores were running low.

The first time he’d tried to buy groceries in Ketchikan, the Safeway manager had simply shaken his head. “We reserve the right to refuse service.” The next day, he tried the IGA. Same story. Then the liquor store, the coffee shop, the general store—all politely declining his business.

At the liquor store, the clerk had at least been honest: “Look, doc, my cousin works at the hospital. I got nothing personal against you, but I also got to live here after you leave.”

“I appreciate the candor,” TooToo had said. “Any chance you could at least sell me some beer?”

“How about I don’t make eye contact with you, and you just… move along?”

“That’s very Alaskan of you. Really captures the frontier spirit.”

His only option had become absurd but necessary: day passes to board the cruise ships.

For sixty-five dollars, any tourist could purchase a day pass to board a docked cruise ship and access its facilities. The cruise lines didn’t care about local boycotts. They didn’t know about his legal battle with PeaceHealth. They just saw another paying customer.

So twice a week, when the big ships came in—the Norwegian, the Celebrity, the Princess—TooToo would row his dingy across the narrows, walk to the docks, and purchase a day pass. Then he’d board like any other tourist and spend three hours stocking up on food from the buffet, buying toiletries from the ship’s store, occasionally treating himself to a beer at the bar.

Wherever he went in Ketchikan—the docks, the parking lot, the hospital—he heard the whispering. He is the doctor. Not “Dr. Medvalli” or even “that surgeon.” Just “the doctor,” spoken like a warning. The way people in old movies said “the vampire” or “the communist.”

The cruise ship crew members thought he was eccentric. “Back again, buddy?” they’d joke. “You really love cruising, huh?”

“I’m conducting important research on buffet efficiency,” TooToo would deadpan, loading his backpack with dinner rolls. “For a paper I’m writing. ‘Comparative Analysis of Shrimp Cocktail Availability Across Major Cruise Lines.’ Very cutting-edge.”

He never explained that he was a board-certified physician with hospital privileges living off Gravina Island because the entire town had collectively decided he couldn’t buy bread. Or that he’d begun rating the ships on a complex scale: Norwegian had better toiletries, but Celebrity’s buffet restocked faster. Princess had the friendliest bartender, which mattered when you were spending $130 a week for the privilege of basic human commerce.

The irony wasn’t lost on him: he’d won the legal battle for hospital privileges, but he had to buy day passes to cruise ships to eat.

His phone buzzed—a rare moment of connectivity. An email from the hospital administrator.

Dr. Medvalli, we’re writing to inform you that due to low patient volume and scheduling efficiency concerns, we’re adjusting the hospitalist coverage model. Your shifts for November have been reduced to one per week. We’ll reassess in December.

One shift per week. Barely enough to maintain privileges, certainly not enough to live on.

TooToo forwarded the email to his attorney—the one who’d cost him seventy thousand dollars and three years of his life to secure these privileges in the first place. He knew what the lawyer would say: This is constructive termination. We can fight this.

They could always fight this. That’s what lawyers did. They fought things. For money. Lots of money. TooToo had learned that the law was less about justice and more about how long you could afford to be technically correct while still being practically destroyed.

But TooToo was tired of fighting. More importantly, he was beginning to understand the game.

PeaceHealth hadn’t wanted to give him privileges because they knew exactly what would happen next. The medical center didn’t need to exclude him officially; the community would do it for them. Every single employee at that hospital lived in Ketchikan. Their kids went to school together. They shopped at the same three grocery stores. They attended the same churches.

And TooToo? He was the outsider who’d sued their hospital.

It didn’t matter that PeaceHealth had violated antitrust law by tying hospital privileges to employment. It didn’t matter that he’d proven they maintained an illegal monopoly on healthcare services in a captive market. It didn’t matter that he was right.

He’d won the battle and lost the war.

A cruise ship horn echoed across the water—one of the big ones, probably the Norwegian Sun or the Celebrity Millennium. TooToo watched it glide toward the dock, three thousand tourists ready to spend three hours in Ketchikan buying salmon jerky and totem pole magnets before returning to their floating city.

The cruise ship would have a doctor, he thought. Multiple doctors, probably. A whole medical center, pharmacy, even a small operating suite. Floating medical infrastructure serving tourists who would never set foot in PeaceHealth Ketchikan Medical Center.

He’d been boarding these ships twice a week just to buy food. The day passes cost sixty-five dollars each—one hundred thirty dollars a week just for the privilege of shopping like a normal human being. He’d smile at the crew, fill his backpack with provisions from the buffet, buy soap and shampoo from the ship’s store, and row back to Gravina before the ship departed.

The other day-pass tourists thought he was quirky. “You really love cruises!” they’d say, seeing him for the third time. He’d nod and smile, not mentioning that he was a board-certified physician with hospital privileges who literally couldn’t buy groceries on land.

Once, a retiree from Minnesota had asked him, “Do you work on the ships?”

“No,” TooToo had said, loading up on mini shampoo bottles. “I’m a doctor.”

Behind him, two crew members had paused mid-conversation. He is the doctor. Even here, on a cruise ship, the whisper had followed him.

“Oh! A ship doctor?” the retiree asked, delighted.

“Not yet,” TooToo said. “But I’m working on it.”

An idea began to form.

TooToo opened his laptop—the battery was at forty percent, he’d have to be quick—and started researching cruise ship employment. The money was terrible, but it came with room and board. More importantly, it came with something he’d lost three years ago: the freedom to practice medicine without having to wage legal war for the privilege.

Or buy day passes just to eat.

Cruise Ship Medical Officer Position Available
Carnival Cruise Lines
Must be Board Certified
Contract: 4-6 months at sea
Benefits: Room, board, travel
Salary: $7,000-$9,000/month

It was a third of what he should have been making at PeaceHealth. But he’d be able to buy groceries without traveling to another city. He’d be able to sleep without wondering if someone would cut his dingy loose in the night.

He’d be able to practice medicine.

The laptop battery died at thirty-two percent—it always did; he’d need to replace it, but how do you replace a laptop battery when you can’t buy anything in your own town?—so TooToo closed it and looked out at the water.

Another cruise ship was approaching. In the distance, he could see Ketchikan itself, the colorful buildings clinging to the hillside, the docks bustling with tourist activity. From here, it looked like a postcard. Charming. Welcoming. The kind of place people put on their bucket lists.

He thought about his colleagues from residency, scattered across the country now, all of them employed by large health systems, all of them complaining about corporate medicine but none of them willing to do what he’d done.

He’d stood up to the monopoly. He’d fought for independent practice. He’d believed, genuinely believed, that winning the legal battle would change things.

What had Dr. Roz said during the deposition? “PeaceHealth is part of this community. We take care of each other.”

And they did. That was the problem. They took care of each other, and TooToo Medvalli, Marxist gastroenterologist from Michigan with his fancy credentials and his legal victories, was not part of that “each other.”

He would never be.

TooToo made his decision that afternoon, as the sun began its early descent behind the mountains. He would apply for cruise ship positions. He would finish out his month of “one shift per week” at PeaceHealth—maintaining his hard-won privileges for exactly long enough to prove a point—and then he would leave.

The hospital would claim he’d voluntarily resigned. His attorney would be furious. The legal community would call it a waste.

But TooToo had learned something important in Ketchikan: you can win every battle and still lose the war. You can be right about the law and wrong about the reality.

You can have privileges and no patients.
Rights and no respect.
Victory and no future.
Hospital credentials and a dependency on cruise ship buffets.

The American Dream, he thought, but for doctors.

As darkness fell over Gravina Island, TooToo lit a small propane heater and ate his beans cold from the can. Tomorrow he would row across to send his applications. Next month, he would be on a ship.

The cruise ships would welcome him. They needed doctors and didn’t care about local politics or community feelings or three-year legal battles. They needed someone board-certified who could handle acute care for tourists who ate too much at the midnight buffet.

From his houseboat, TooToo watched one more cruise ship pass. He didn’t wave this time.

He just watched it

This is a work of fiction. While it references real places and institutions, all characters and events are imaginary and satirical in nature.

Oskar Rausch is a researcher at the Make America Constitutional Again Institute (MACAI) in San Juan, Puerto Rico. He can be contacted at oskar.rausch@proton.me.

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Due to unusually high call volumes

The strain of the COVID-19 pandemic on society and healthcare systems turned fine fault lines into gaping canyons. Reflecting on my writings about U.S. hospitals 5 years ago, I asked myself what had changed and what still must change to rebuild a healthcare system that can deliver medical care wherever and whenever it’s needed. What problems were prevalent in the healthcare system before the pandemic, and how did the pandemic highlight these deficiencies? In my day-to-day work as a doctor, what diverts my time and energy away from the most important and fulfilling aspect of doctoring – patient care?

Direct and effective communication with patients is the most important aspect of healthcare, in my view. A doctor working in the community who is licensed and certified has demonstrated a body of knowledge and skills to provide medical care within a certain scope of practice. Someone with a health concern is arguably not seeking the smartest doctor they can find; they want a doctor with whom they can communicate their concerns, understand their health issue, and make a mutually acceptable treatment plan. In daily practice, I feel that 95% of my time and energy are consumed by tasks that do not relate directly to patient care. Even more unfortunate is the fact that these 95% of tasks are the ones by which doctors are evaluated and compensated: clicking through electronic health records (EHR), wrestling with flawed communication systems (such as hospital phones, pagers, texting, and email) to receive and share information with other members of the healthcare team, answering “queries” from hospital administration for the purpose of billing patients and insurance companies, and wasting life-years trying to wrangle health information systems as mandated by hospital administrators and insurance companies.

1. The world wide web

The pandemic pushed the role of “telemedicine” (healthcare rendered by phone or digitally) into the foreground as a way to deliver healthcare efficiently while reducing the spread of the coronavirus. Regrettably the first and biggest problem with healthcare is internet connectivity and how EHR software sends and receives information between a doctor’s phone/computer and the hospital server. Even in the year 2020, reliable, high-speed internet is a scarce resource in the United States. Most Americans have no choice of internet service provider, if they are lucky to even have access to one. In a time where human resources are stretched thin and inefficiently used, trying to reach a human in the event of a service interruption can easily waste hours if not days waiting on hold or confined to chatbot purgatory. Many doctors now work remotely to a large extent, if not entirely. Reliable, fast internet is prerequisite to being able to deliver good healthcare. This is especially true because of the nature of EHRs, which use “Virtual Machines” and “Remote Desktops” that require a reliable, low-latency, high-speed internet connection. A client that runs at a snail’s speed and frequently disconnects, requiring 10 minutes to repeat the authentication process before dropping the connection again, is severely detrimental to patient care.

2. Electronic Health Records

EHRs are essentially spreadsheets in fancy packaging. They’re not smart in the sense that a phone is smart; they don’t learn, predict, or automate tasks. In fact software that is slow, requires a lot of clicking and non-intuitive behavior, and which wastes a lot of time with authentication and logging in, is not much better than typing text into the simplest text editor and saving it in a rudimentary database. That is the core of a hospital or clinic’s information system: text and media files saved chronologically and accessible to the right people at the right time. I prefer to type or dictate notes freestyle rather than use templates because it’s faster for me, gives me more control over the document, and helps me communicate my assessment and treatment plan more effectively than relying on a template created by someonen else who may conceptualize a diagnostic process and treatment plan much differently than their peers. An ideal EHR to me would simply be typed into a Unix terminal (for a reader unfamiliar with Unix, imagine a black screen with a flashing white cursor) and piped into a hospital server, which would then use the text to help doctors appreciate the clinical Gestalt or “big picture”: what could harm or kill the patient in the next few hours? And beyond the first 12-24 hours, how to safely discharge the patient? As an EHR user, I don’t want a fancy front-end trickling through a lagging virtual machine; I want a simple, low-latency, text-focused interface and a smart backend, in other words, very simple software that looks dumb but is actually smart.

3. Communication

On top of the pressure of having to synthesize a huge amount of dynamic information to make fast and sound decisions about patient care, doctors are inundated and constantly interrupted by communications from other members of the care team. Doctors work closely with nurses, aids, phlebotomists, lab and radiology technicians, doctors from different specialties, clerks, social workers, insurance companies, and hospital administrators. There is a lot of information constantly moving back and forth in real-time between all parties. This flow of information is often like a waterfall rather than a water faucet – the communications are not prioritized and frequently fail to reach the right person at the right time. There are times when a doctor’s attention should be focused entirely on the task at hand, for example when assessing or speaking with a patient at bedside. This is no time to be interrupted with billing queries or non-urgent questions about other patients’ care. A constant stream of unprioritized and unfocused information can make it extremely difficult to focus on the critical 1% of information which can hurt patients if this information is not processed correctly at the right time. In order to hold people accountable for their decisions, they need to be given a fair chance, with tools that work without draining life out of the users. A page or phone call that may or may not find the intended recipient, and a note left in the EHR saying, “tried to call you but you didn’t answer your phone,” is subjective and not constructive without a way for all parties to track communications from their origin to their destination.

Automated spam calls, a nuisance in daily life, can be harmful to patient care by hindering timely and effective communication

In addition to the right tools, there is a need for sound systems. A doctor’s extensive education and training culminates in a highly specialized set of skills and knowledge. Doctors should take pride and joy in their work; they endured long, grueling training out of a desire to help humanity. Out of training, doctors traditionally became their own bosses, working in community hospitals or private clinics, practicing medicine the way they were taught in a style that becomes their own. Nowadays doctors are managed by administrators who are not doctors. There is a reason why healthcare systems look and function the way they do, an evolutionary end-product of decades of legislative, financial, operational, and societal forces exerting themselves on doctors and hospitals. Back in the day, doctors saw their own patients in their own clinic and treated their patients when they were hospitalized too. This is exceptional nowadays. There was no, “I’m your doctor for today,” or “I’m your doctor this shift, until 8pm.” The reality is that this mode of doctoring has become rare. Having experienced the modern-day flavor of corporate medicine in urban areas and the more traditional model in rural areas, I appreciate the pros and cons of both models. “I’m your doctor, period” can be spoken by a doctor lucky enough to escape corporate medicine, but also a doctor prepared to withstand the stress of not having any personal or protected time away from work. Too many talented doctors nowadays burn out after short-lived clinical careers, depriving patients of the care of great doctors who fell victim to the 95% non-clinical burden on top of the already stressful 5% clinical work.

4. More communication

There is a clear line between “outpatient” and “inpatient” medicine in most doctors’ minds, that is, healthcare delivered in a clinic, where a patient goes to an appointment and returns home, compared to a hospital, where a patient stays overnight. Patients don’t think in terms of “inpatient” and “outpatient.” A patient who wakes in the middle of the night with a fever and shortness of breath, or a patient with a growing breast lump, have concerns that needs to be addressed immediately by someone who actually cares. It sounds obvious, but I could not copy and paste this phrase too many times: by someone who actually cares. Not a voice menu, not a chatbot, not “Due to unusually high call volumes…,” and not a tired, under-paid clerk who is poorly equipped to do their job. A doctor has the knowledge to assess whether a problem is urgent or not urgent, concerning or likely harmless. It’s not fair or realistic to expect patients, lacking specialized knowledge, exposed to the vast informational waste littering cyberspace, biased by personal experience and anxiety about a health condition, to make those calls.

“Due to unusually high call volumes…” has become this year’s mantra. Nearly every call I attempt to place to an insurance company, hospital, or clinic is met with this phrase and indefinite wait times, now nine months since the start of the pandemic. Most negative feedback about doctors and hospitals relates to what goes on beyond the few minutes a doctor spends interacting directly with the patient: a medical assistant having a bad day, a disorganized clinic, the insurance labyrinth, bills…human concerns not being reciprocated by a human in a place to care and do something about it. Most of the time and energy spent by patients trying to get help for a health concern is burned in the friction of waiting on hold and clicking through websites to try and make appointments or navigate insurance and billing departments. Putting this burden on healthy people is absurd. This is a lot of life wasted by a lot of people. There needs to be a much less painful way to pick up the phone and route a health concern to someone with the expertise to address the concern. Putting this burden on someone who is sick and possibly dying is criminal.

5. Paying for healthcare

Healthcare is too expensive to fund primarily through private insurance. This is the clearest take-home point of the pandemic to me as a doctor and as a patient. I recently “downgraded” my health insurance because it is by far my biggest monthly expense after my mortgage. For the past year, I purchased expensive health insurance and hardly used it. Miss a payment, and insurance companies will not hesitate to end coverage as soon as the clock strikes twelve, as swiftly and thoughtlessly as a robot. I am fortunate enough to have a job. Many people do not and were already barely just getting by before the pandemic. We no longer have the luxury of deciding whether or not a single payer system is good for America. We are well past that point. Healthcare, especially now, can only be funded by a payer pool on a national level. In my view, healthcare is a human right. This is not a political issue to me. This is a human issue. Everyone should have access to at least a basic level of healthcare: when you have a health concern, you should be able to see a healthcare professional as quickly enough as the issue warrants, without breaking the bank, without bankrupting society.

I had the opportunity to work in German hospitals during my medical school international rotations. There is no such thing as uninsured in Germany, and many other countries with nationalized healthcare. Everyone can get urgent and non-urgent healthcare without going bankrupt. In my view, universal healthcare (and access to universally affordable education) is the foundation of a sound, healthy society. How much money one has in the bank should not delay access to healthcare. Those with the means to purchase private health insurance are free to do so, along with the benefits this might entail. The reality is that healthcare is expensive. Diagnostics and therapeutics – CT scans, MRIs, lab tests, prescription drugs – cost money to develop and deliver. We are all humans, and illness is inseparable from the human experience. Everyone will have contact with the healthcare system at some point in their life, and most Americans are born and die in hospitals. The sooner we accept this reality and have empathy for the suffering of others, the sooner we can make better decisions for how our healthcare system will look and function in the recovery period following the pandemic.

Omar Metwally, MD // 16 December 2020

omar@analog.earth