Posted on by omarmetwally

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

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

The Last Download

The Last Download

A Dispatch from The Medical Factory Without a Name (MFWN)

Slow Rapids, Michigan

By Oskar Rausch
17 December 2025

Prologue: The Cliff

They met on the roof of the parking structure, as they always did.

The wind came off the Detroit River carrying the smell of industry and decay—the ancient perfume of Southeast Michigan, unchanged since the first Model T rolled off the line. Twelve stories below, the ambulances came and went, their sirens dopplering into the evening traffic. The hospital sprawled beneath them like a sleeping beast, its windows glowing with the soft light of suffering and healing and endless, endless documentation.

Dr. Sogamawa stood at the edge, his Brioni suit jacket flapping in the wind. Not a white coat—TooToo noted this, as he always noted it. Sogamawa hadn’t worn a white coat in decades. He’d traded it for worsted wool and French cuffs somewhere around the time he’d traded patients for “stakeholders” and medicine for “healthcare delivery optimization.” The suit was charcoal, impeccably tailored, the kind of suit that communicated “I am a physician who has transcended medicine.”

TooToo Medvalli approached from the stairwell door, his own white coat stained with coffee and creased from fourteen hours on service, his pager clipped to his belt, his phone conspicuously absent from his hand. He walked slowly, deliberately, the way a man walks when he knows he is being watched and has decided not to care.

“You came,” Sogamawa said.

“You summoned.”

“I invited.”

“There’s no difference. Not anymore.”

The wind gusted between them, carrying a candy wrapper from some visitor’s pocket, sending it spiraling into the void. Below, a helicopter approached the trauma pad, its rotors beating the air into submission.

“It didn’t have to be this way,” Sogamawa said. “You could have downloaded the app. Everyone else downloaded the app.”

“Everyone else surrendered.”

“Everyone else adapted. That’s what professionals do, TooToo. They adapt to institutional requirements. They understand that individual preferences must yield to collective infrastructure.”

“They yield to lies.”

“They yield to systems.”

“Your system lies.” TooToo stepped closer, close enough to see the fine stitching on Sogamawa’s lapel, the understated gleam of his cufflinks, the silk pocket square folded into precise peaks—small details that communicated expense without appearing to try. “It tells nurses I’m available when I’m not. It tells the institution that communication has occurred when it hasn’t. It substitutes the appearance of function for function itself.”

“It provides documentation.”

“Documentation of what? Of a lie? Of a green dot that means nothing?”

Sogamawa turned to face him fully. The setting sun caught his face, casting half of it in shadow—an accident of timing that he had almost certainly planned.

“Let me tell you what I see when I look at you,” Sogamawa said. “I see a physician who has confused stubbornness with principle. I see a man who would rather carry a device from the 1990s than participate in the communication infrastructure of a modern health system. I see someone who has made himself a symbol of resistance without asking whether resistance serves anyone but his own ego.”

“And when I look at you,” TooToo replied, “I see a suit.”

Sogamawa’s expression flickered—just for a moment.

“I see a man who went to medical school, presumably because he wanted to help people, and somewhere along the way decided that helping people was less interesting than managing the people who help people. I see someone who traded a white coat for a Brioni jacket, traded patients for org charts, traded medicine for an MBA.”

“My administrative credentials—”

“Are exactly the problem.” TooToo gestured at Sogamawa’s suit, at the whole manicured presentation of him. “When’s the last time you saw a patient? Not a ‘stakeholder.’ Not a ‘healthcare consumer.’ A patient. A human being who was sick and scared and needed a doctor.”

“I serve patients at a systems level—”

“You serve spreadsheets. You serve dashboards. You serve compliance metrics that tell you what you want to hear while the actual work of medicine happens twelve floors below you, done by people in white coats with pagers that actually work.”

“The pager is obsolete.”

“The pager is honest. It doesn’t have an MBA. It doesn’t attend leadership seminars. It doesn’t show me as ‘available’ when I’m in the middle of a code. It just… works.”

TooToo stepped closer still, close enough that Sogamawa could smell the hospital on him—the antiseptic, the coffee, the faint undercurrent of human suffering that never quite washed out.

“You sold out,” TooToo said. “Somewhere along the way, you decided that being a doctor wasn’t enough. You wanted to be important. You wanted the corner office and the windows and the seat at the table where decisions get made. And now you’re here, on a rooftop, trying to force a physician to install a broken app on his phone because a dashboard somewhere needs a green dot.”

“I’m trying to run a hospital.”

“You’re trying to run a business. There’s a difference. There used to be a difference. People like you have spent twenty years erasing that difference, and people like me are what’s left of the resistance.”

The helicopter landed below them, its rotors slowing. Somewhere in the hospital, a trauma team was assembling, pagers buzzing—no, phones buzzing, apps notifying, green dots pulsing with false availability.

“I’m giving you one more chance,” Sogamawa said. His voice had hardened now, the veneer of collegiality cracking. “Download the app. Tonight. I’ll know if you do—the system will show your status. Tomorrow morning, when I check the compliance dashboard, I want to see your name with a green dot. I want this to be over.”

“And if I refuse?”

“Then tomorrow afternoon, you’ll receive a meeting invitation. Conference Room 5-J. And we’ll resolve this another way.”

TooToo looked at him for a long moment. The sun had fully set now, leaving only the ambient glow of the parking structure lights and the distant shimmer of the city.

“I’ve been a physician for twenty-three years,” TooToo said. “I’ve adapted to EMRs and HIPAA and meaningful use and MACRA and prior authorizations and peer review and maintenance of certification. I’ve adapted to more administrative requirements than you’ve had leadership retreats. I adapt constantly. What I don’t do is pretend that broken systems work. What I don’t do is participate in lies. What I don’t do is take orders from a man who forgot what a stethoscope feels like.”

“Then I’ll see you tomorrow.”

“You’ll see me tonight. On rounds. In my white coat. With my pager. Doing the job you abandoned.”

TooToo turned and walked back toward the stairwell door.

“TooToo.”

He stopped but didn’t turn.

“When this is over,” Sogamawa said, “I want you to know—it wasn’t personal. It’s never personal. It’s just… optimization.”

TooToo opened the door.

“That’s exactly the problem,” he said. “It should be personal. Healthcare should be personal. The moment it becomes optimization, it stops being care. But you wouldn’t know that, would you? You optimized yourself out of caring years ago.”

The door closed behind him.

Sogamawa stood alone on the roof, the wind pulling at his suit jacket, watching the helicopter’s rotors spin down to silence. His hand went to his tie—silk, Italian, a gift from the hospital board after last year’s quality metrics exceeded targets.

Tomorrow, he thought. Tomorrow we optimize Dr. Medvalli.

He pulled out his phone and opened Mobile Heartbeat. The screen glowed with names and green dots, a constellation of compliance, a galaxy of availability.

One name remained gray.

Dr. TooToo Medvalli – Offline

Not for long.

Part One: The Resistance

The resistance, such as it was, numbered seven physicians at its peak.

There was TooToo, of course—the ideological core, the one who had actually read the app’s privacy policy and discovered it required microphone access for an application whose sole purpose was text-based communication. (“Why does a pager replacement need to hear me?” he had asked IT. IT had not responded.)

There was Dr. Trisha Morgan, a hospitalist who had simply never gotten around to downloading it and kept claiming her phone was “incompatible.” Her phone was an iPhone 14. It was compatible with everything except her willingness to be surveilled.

There was Dr. Richard Shih, who had downloaded Mobile Heartbeat, watched it crash four times in one shift, and uninstalled it with the grim satisfaction of a man who had been proven right about something he wished he’d been wrong about.

There were four others—two surgeons, an intensivist, and one very old cardiologist who claimed not to own a smartphone and whom no one had the energy to contradict.

Seven physicians. Out of four hundred. The Magnificent Seven, TooToo called them, though no one else used this term and Trisha had actively asked him to stop.

* * *

The final memo arrived on a Tuesday.

Effective immediately, all clinical communication will transition exclusively to the Mobile Heartbeat platform. Pager support will be discontinued. Physicians who have not downloaded and activated MH-Cure by Friday will be required to attend a mandatory compliance session with Dr. Sogamawa.

The language was careful. It did not say there would be consequences. It did not threaten termination or privilege suspension. It simply noted that a meeting would occur—a meeting with the CMO, a meeting where one would sit across from Dr. Sogamawa and explain why one had chosen to be the problem.

No one wanted to be the problem.

By Wednesday, the four others had surrendered. The surgeons claimed they’d been meaning to download it anyway. The intensivist said something about “picking battles.” The old cardiologist’s son had apparently bought him a smartphone and installed the app for him, which everyone agreed was a heartwarming story of family and not at all an act of technological violence against an elderly man.

By Thursday, it was just TooToo, Trisha, and Richard.

* * *

“They’re going to make us download it in front of him,” Trisha whispered.

They were in the physician lounge, which was really just a windowless room with a coffee machine and a couch that smelled vaguely of despair. The good lounge—the one with the view and the espresso maker—was reserved for administrators. And physicians who had become administrators. And physicians who had traded their white coats for Brioni suits.

“They can’t force us to install software on our personal devices,” Richard said.

“They can make it very uncomfortable to not install software on our personal devices,” Trisha replied.

TooToo was reading his pager. A nurse from 4 West had sent him a page: PT IN 412 NEEDS EVAL FOR CHEST PAIN. Clear. Direct. Received.

“I got a page,” he said.

“From who?”

“Nurse on 4 West.”

“How did she page you? Pagers aren’t supposed to work anymore.”

“She called the operator and asked for my contact preference. My pager number is in the system. It’s always been in the system.”

Trisha stared at him. “That’s not efficient.”

“It took her an additional thirty seconds.”

“The whole point of Mobile Heartbeat is that it’s faster.”

“The whole point of Mobile Heartbeat is that it looks faster. Looking faster and being faster are not the same thing. Looking like communication and actually communicating are not the same thing. But that’s the whole ethos now, isn’t it? Looking like healthcare instead of being healthcare. Sogamawa’s whole career is built on looking like a physician instead of being one.”

Richard stood up. “I’m going to download it,” he said. “I’m sorry. I have two kids. I can’t—”

“No one’s judging you,” TooToo said.

“You’re judging me.”

“I’m observing you. Judgment is a separate process.”

Richard left.

Trisha looked at TooToo. “What about you?”

“What about me?”

“Are you going to download it?”

“No.”

“They’ll document it. They’ll put it in your file. They’ll bring it up at reappointment.”

“Yes.”

“Doesn’t that concern you?”

TooToo considered the question. Outside the window—not that there was a window—a hospital was functioning. Nurses were messaging doctors who weren’t receiving pages. Broadcasts were broadcasting to no one. Somewhere, an app was displaying a physician as “online” while that physician was elbow-deep in a surgical abdomen with no phone in sight.

“There are many things that concern me,” he said. “Whether MFWN documents my preference for functional communication is not one of them.”

Part Two: The Execution

They came for him on Friday at 2:47 PM.

TooToo was in the physician lounge, eating a granola bar and reviewing labs on his laptop, when the door opened and two men in suits entered. He recognized one of them: Leonardo Tortellini, Director of Medical Staff Affairs. The other was unfamiliar—younger, with the blank expression of someone who had been hired specifically to not have expressions.

“Dr. Medvalli,” Leonardo said. “Dr. Sogamawa would like to see you.”

“I’m aware. The meeting is at three.”

“The meeting has been moved up.”

“To when?”

“To now.”

TooToo closed his laptop. “I see.”

“Your phone, please.”

TooToo looked at him. “Excuse me?”

“Your phone. We’ll need it for the meeting.”

“Why would you need my phone for a meeting?”

“Compliance verification.”

“What the hell does that mean?”

The expressionless young man stepped forward. “Dr. Medvalli, we can do this the easy way or the documented way.”

TooToo almost laughed. “Did you just threaten me with documentation?”

“I’m informing you of process.”

“You’re informing me that you’ve confused process with intimidation.”

Leonardo sighed. “TooToo. Please. Just come with us. Bring the phone.”

* * *

The walk to the fifth floor was silent.

TooToo had expected to be taken to Sogamawa’s office—the one with the carpet and the windows and the carefully curated artwork meant to communicate “I am a physician who also understands leadership.” Instead, they turned left at the elevator bank and continued down a corridor he’d never noticed before, past Human Resources, past Legal, past a door marked “CONFERENCE ROOM 5-J” that looked like it hadn’t been opened since the hospital was still called Blokewood.

Leonardo knocked twice. The door opened.

The room was small and windowless—unusual for the executive floor, where windows were distributed according to rank like military decorations. A single table sat in the center, bare except for a laptop and a smartphone still in its packaging. Three chairs lined the far wall, occupied by people TooToo didn’t recognize: two women in business casual, one holding an iPad, the other a camera.

Dr. Sogamawa stood at the head of the table. He was wearing a different suit than last night—navy, this time, with a subtle pinstripe that probably cost more than a resident’s monthly salary. Still no white coat. Never a white coat.

“Dr. Medvalli. Thank you for joining us.”

“I wasn’t aware I had a choice.”

“You always have choices. That’s what this meeting is about.”

TooToo looked at the camera. “Are we being recorded?”

“For documentation purposes.”

“Documentation of what?”

“Your compliance session.”

“And if I don’t consent to being recorded?”

“Then we document your refusal to participate in the compliance process.”

TooToo felt something cold settle in his stomach. This wasn’t a meeting. This was theater. The camera, the witnesses, the windowless room—this was a production, and he was the final scene.

“What do you want?” he asked.

Sogamawa gestured to the floor in front of the table. “Please. Kneel.”

TooToo stared at him. “I’m sorry?”

“Kneel. It’s part of the process.”

“What process requires a physician to kneel?”

“The compliance process.”

“That’s not a real thing. You’re making this up as you go.”

Sogamawa’s expression didn’t change. “Dr. Medvalli, you have been non-compliant with hospital communication policy for eight months. You have ignored memos. You have refused to download mandated software. You have made yourself a symbol of resistance to institutional progress. This is your opportunity to demonstrate your commitment to the team.”

“By kneeling.”

“By participating in the compliance process.”

“Which involves kneeling.”

“It involves demonstrating humility.”

“It involves demonstrating submission. To a man in a pinstripe suit who hasn’t touched a patient in a decade.”

Sogamawa’s jaw tightened almost imperceptibly. “My clinical experience—”

“Ended when you decided being a doctor wasn’t prestigious enough. When you decided you’d rather be the one giving orders than the one following them. When you traded the white coat for—” TooToo gestured at the suit. “For that. What is that, Armani?”

“It’s not relevant.”

“It’s entirely relevant. You’re asking me to kneel before a man who spent two hundred thousand dollars on medical school and then decided medicine was beneath him. You’re asking me to submit to someone who optimized himself out of the profession.”

The expressionless young man—Leonardo’s companion—stepped forward. TooToo noticed for the first time that he was holding something: a black cloth bag, the kind that might be used to transport wine bottles or cover the head of someone being transported to a location where documentation was the only witness.

“Dr. Medvalli,” Leonardo said. “Please kneel.”

TooToo looked at the bag. He looked at the camera. He looked at Sogamawa, who was watching him with the patient expression of a man who had done this before, who would do this again, who understood that institutions outlast individuals and that documentation was forever.

“You know what the difference is between us?” TooToo said. “I became a doctor to help people. You became a doctor to become something else. Every decision you’ve made since medical school has been about climbing—residency as a stepping stone, fellowship as a credential, the MBA as an escape hatch from actual medicine. And now you’re here, in a windowless room, asking a physician to kneel because he won’t install a broken app.”

“This isn’t about the app.”

“It’s entirely about the app. It’s about your need to have a green dot next to every name on your dashboard. It’s about your inability to tolerate anyone who questions the systems you’ve built. It’s about control dressed up as optimization.”

“It’s about compliance.”

“Compliance with what? A lie? A system that tells nurses their messages are delivered when they’re not? A platform that shows me as available when I’m unavailable?” TooToo shook his head. “You want me to comply with fiction. You want me to participate in institutional make-believe. And when something goes wrong—when a patient is harmed because a nurse believed Mobile Heartbeat when she shouldn’t have—you’ll point to the documentation and say ‘but he was compliant. The green dot was green.'”

“Kneel, Dr. Medvalli.”

“No.”

“Kneel.”

“No.”

Leonardo nodded to the expressionless young man, who moved with the efficiency of someone who had been trained for exactly this moment. Before TooToo could react, his arms were pinned behind his back. He felt the cloth bag descend over his head, smelled the faint chemical scent of new fabric, heard his own breathing amplified in the sudden darkness.

“This is assault,” he said, his voice muffled.

“This is documentation,” Sogamawa replied.

TooToo felt himself being pushed downward. His knees hit the carpet—commercial grade, thin, offering no cushion. Someone was binding his wrists with what felt like zip ties. He could hear the camera clicking, the soft whir of video recording, the sound of his own resistance being captured for institutional posterity.

“Dr. Medvalli,” Sogamawa’s voice came from somewhere above him. “You are being offered a final opportunity to comply with MFWN’s communication infrastructure requirements. Do you accept this opportunity?”

“Go to hell. Go directly to hell. Do not pass Go. Do not collect your performance bonus.”

“Let the record show that Dr. Medvalli has declined the opportunity for voluntary compliance. We will now proceed with assisted compliance.”

TooToo heard footsteps. Felt someone crouch beside him. Heard the rustle of fabric as hands searched his pockets.

“Got it,” Leonardo said. “iPhone 12. Passcode?”

“I’m not giving you my passcode.”

“Face ID?”

TooToo felt hands grip his head through the cloth bag, tilting his face upward. The bag was lifted just enough to expose his face—his eyes, specifically—and he saw the blur of his own phone being held in front of him. The familiar click of Face ID unlocking.

“Thank you for your cooperation,” Sogamawa said.

The bag was pulled back down.

TooToo knelt in darkness, listening to the sounds of his own phone being violated. The tap of fingers on glass. The whoosh of the App Store opening. The soft chime of a download beginning.

“MH-Cure White,” Leonardo announced. “Downloading now.”

“Let the record show,” Sogamawa said, “that Dr. Medvalli’s device is being brought into compliance with hospital communication policy.”

“You’re proud of this, aren’t you?” TooToo said into the darkness. “This is probably the closest you’ve felt to being a real doctor in years. Finally doing something with your hands.”

Silence.

“That’s the tragedy,” TooToo continued. “You could have been good. You could have helped people. Instead you’re standing in a windowless room, supervising the forced installation of a broken app on a bound colleague’s phone, and you’re telling yourself it’s leadership.”

“This is optimization.”

“This is pathology. And somewhere, deep down, in whatever part of you still remembers why you went to medical school, you know it.”

The download chime sounded. Then another series of taps—configuration, permissions, the granting of access to microphone and camera and location that TooToo had refused to grant for eight months.

“Installation complete,” Leonardo said. “He’s showing as online.”

“Excellent.” Sogamawa’s voice carried the satisfaction of a man checking a box. “Let the record show that Dr. Medvalli is now compliant with MFWN’s communication infrastructure. His status on Mobile Heartbeat is active. His availability indicator is green.”

TooToo laughed. He couldn’t help it. The absurdity was too complete.

“Something funny, Dr. Medvalli?”

“My availability indicator is green,” TooToo said. “I’m bound and hooded on the floor of a windowless room, and my availability indicator is green. That’s the whole problem, summarized in a single moment. That’s your whole career, summarized in a single moment. The appearance of function. The documentation of success. The green dot that means nothing.”

Silence.

Then: “Remove the hood.”

Light flooded back. TooToo blinked, adjusting, and found himself looking up at Sogamawa, who was holding TooToo’s phone. The Mobile Heartbeat app was open. The little green dot pulsed next to TooToo’s name.

Dr. TooToo Medvalli – Available

Sogamawa crouched down, bringing his face level with TooToo’s. This close, TooToo could see the details—the expensive moisturizer, the precisely trimmed eyebrows, the faint lines around the eyes that spoke of stress managed through spa treatments rather than resolved.

“You can go now,” Sogamawa said.

“You’re letting me go?”

“You’re compliant. There’s nothing left to document.”

Leonardo cut the zip ties. TooToo stood slowly, his knees aching, his wrists marked with red lines. The women in the chairs were still recording. The camera was still running.

“My phone,” TooToo said.

Sogamawa handed it to him. The Mobile Heartbeat app stared back, cheerful and green.

“You understand,” Sogamawa said, “that if you uninstall the app, we’ll know. The system monitors compliance. We’ll see your status go offline, and we’ll schedule another session.”

TooToo looked at the phone. Looked at Sogamawa. Looked at the camera.

“Can I say something for the documentation?”

“Of course.”

TooToo held up the phone, showing the green availability indicator to the camera.

“This app says I’m available. I’m not available. I’m standing in a windowless room after being bound and hooded by hospital administrators who forcibly installed software on my personal device. I am, in every meaningful sense, the opposite of available. But the app says I’m available, and the app is what matters, because the app is what gets documented, and documentation is what gets measured, and measurement is what gets managed, and management is what this institution believes healthcare to be.”

He pointed at Sogamawa.

“This man went to medical school. He took the same oath I took. He promised to do no harm. And today he supervised the physical restraint of a colleague over a software installation. That’s what the MBA does to medicine. That’s what optimization culture does to physicians. It turns doctors into enforcers and hospitals into compliance factories.”

He lowered the phone.

“I will not uninstall the app. I want it on my phone. I want the green dot. I want the lie to be visible, documented, recorded—evidence of what compliance actually means in this institution. When a patient has an adverse event because a nurse believed Mobile Heartbeat delivered a message that it didn’t, I want this video to exist. I want people to see what this hospital’s leadership values.”

He walked to the door.

“Dr. Medvalli,” Sogamawa said. “This is documented.”

“I know.” TooToo opened the door. “So is this: you used to be a doctor. Now you’re a loser in a nice suit.”

He left the door open behind him.

Epilogue: Six Months Later

Dr. TooToo Medvalli was not offered contract renewal at MFWN. The documentation cited “cultural misalignment with institutional values.” The video of his compliance session was never released, but it was never deleted either. It sat on a server somewhere, preserved for documentation purposes, evidence of a problem that had been solved.

TooToo kept the app on his phone. He kept the green dot. He showed it to colleagues at conferences, at job interviews, at late-night gatherings where physicians shared stories of administrative absurdity.

“They hooded me,” he would say, showing the pulsing green indicator. “They bound my wrists. They forced my face into the camera to unlock my phone. And then they installed an app that says I’m available. That’s what modern healthcare leadership looks like. That’s what happens when MBAs run medicine.”

People laughed. People shook their heads. People said “that’s insane” and “that couldn’t really happen” and “you should sue.”

TooToo never sued. Lawsuits required documentation, and documentation was their language, not his.

Instead, he heard about an opening in Alaska. A small town called Ketchikan. A hospital called PeaceHealth. They needed hospitalists, and they didn’t ask about his communication preferences during the interview.

He took the job.

He brought the pager.

He kept the app installed—a small green lie, pulsing in his pocket, a reminder of what he was leaving behind and what, perhaps, lay ahead.

* * *

Trisha Morgan downloaded Mobile Heartbeat voluntarily the following week. She did not attend a compliance session. She did not ask what had happened to TooToo. Some questions were better left undocumented.

Dr. Richard Shih left MFWN four months later. His exit interview cited “better opportunities.” The documentation noted his departure as voluntary.

The very old cardiologist died. His son inherited the smartphone. The Mobile Heartbeat app continued to show the cardiologist as “available” for three weeks after the funeral, until someone in IT finally updated the status. For twenty-one days, the dead man had a green dot.

Dr. Sogamawa was promoted to Regional Chief Medical Officer. His new office had floor-to-ceiling windows and a view of the river. He never wore a white coat again.

ATTACHMENT

Sampling of user reviews for the MH-Cure application (iOS: 2.2/5 stars from 20 ratings; Android: 1.3/5 stars from 12 ratings). Selected review: “Mobile Heartbeat is an unreliable communication app… This week mobile heartbeat was not working and we had no way to communicate with other departments in the hospital. This is 100% unacceptable.”

The review was documented.

The app was not changed.

The green dots kept pulsing.

DISCLAIMER: The Last Download is a work of satirical fiction. All characters, institutions, and events depicted are entirely fictional. “The Medical Factory Without a Name,” “Slow Rapids, Michigan,” Dr. TooToo Medvalli, Dr. Sogamawa, and all other persons and places are products of the author’s imagination. Any resemblance to actual persons, living or dead, or actual healthcare institutions is purely coincidental. The “compliance session” depicted is an absurdist exaggeration intended as satire—no actual hospital would hood and restrain physicians over app installations. Probably. The app reviews quoted in the attachment, however, are inspired by real user feedback. This story is intended as commentary on healthcare administration culture, communication technology mandates, and the growing tension between institutional metrics and clinical reality. It should not be construed as medical advice, legal advice, or instructions for resisting your own hospital’s IT department.

Posted on by omarmetwally

The Medical Factory Without a Name

The Medical Factory Without a Name

Healthcare-Adjacent Revenue Optimization Since 2018

— PRESS RELEASE • FOR IMMEDIATE DISTRIBUTION —

Detroit-Area Health System Completes Fifteenth Merger, Rebrands as “The Medical Factory Without a Name”

New ownership promises “streamlined patient processing” and “industry-leading liability avoidance”

SOMEWHERE IN MICHIGAN — The health system formerly known as Blokewood, then Medical Mountain, then Boervell, then a series of increasingly forgettable names, announced today that it has completed yet another merger and will henceforth be known as The Medical Factory Without a Name (MFWN).

“We found that every time we had a name, people kept associating it with things like ‘patient outcomes’ and ‘physician concerns,'” said a spokesperson. “By eliminating our name entirely, we’ve eliminated accountability. It’s really a win-win, except for patients, but they’re not shareholders.”

The acquisition was financed by an international investment consortium whose members prefer to remain anonymous for “tax purposes and also other purposes.”

New Leadership Announced

Chief Executive Officer: A private equity algorithm that has never seen a patient but has seen a spreadsheet

Chief Medical Officer: A physician who hasn’t touched a patient since his residency but remains very concerned about protocol

Chief Financial Officer: Three venture capitalists in a trench coat

Chief Experience Officer: An AI chatbot that responds to all patient complaints with “We value your feedback. Let’s talk tomorrow.”

A Message from Leadership

“At The Medical Factory Without a Name, we believe healthcare is too important to be left to doctors. That’s why we’ve implemented industry-leading policies that ensure no nurse will ever have to make a medical decision again. Or any decision. Decisions are a liability.”

— CEO, in a statement issued by the CFO and approved by legal

When asked about the recent departure of several long-tenured physicians, the Chief Medical Officer released the following statement:

“Per policy, I cannot comment on personnel matters. I can only comment on policy. Our policy is to have policies. We feel very strongly about this. Sorry.”

The CEO added: “We’re aware some physicians have expressed concerns. We look forward to scheduling a meeting to discuss those concerns at a future date. Possibly tomorrow. Or the tomorrow after that.”

Patient Care Updates

Under new management, The Medical Factory Without a Name will implement several exciting changes:

  • Consent forms will now be required for all procedures, including being looked at by a physician, being thought about by a physician, and breathing in a way that could be construed as accepting treatment
  • Blood transfusions will require approval from the patient, the patient’s estranged family, and their friends down at the gas station
  • Patients lacking decision-making capacity will be assessed by whichever psychiatrist the CMO finds most agreeable, ensuring that all patients are deemed competent to refuse care they desperately need
  • Physicians who disagree with administrative decisions will be offered counseling, a meeting tomorrow, and a lovely severance package in exchange for signing a document they’re not allowed to read

Community Commitment

“We remain committed to this diverse community. All patients—regardless of race, religion, or creed—will receive the same level of administratively-approved, liability-minimized, policy-compliant care. Which is to say, they will all be processed equally.”

When asked what “processed” means, the spokesperson replied: “That’s a great question. Let’s talk tomorrow.”

Looking Ahead

The Medical Factory Without a Name anticipates another merger within 18-24 months, at which point it will rebrand as An Unnamed Healthcare-Adjacent Revenue Optimization Center or possibly just a QR code that links to a form.

“The future of medicine isn’t medicine. It’s documentation. And we’ve never been more documented.”

— CEO

The Medical Factory Without a Name

We’re Not a Hospital. Not Tonight. Not Ever Again.™

For media inquiries, please submit a written request, which will be reviewed tomorrow.

ABOUT THE AUTHOR

Oskar Rausch spent twenty-three years as a healthcare litigator in the United States, representing hospitals, physicians, and the occasional patient who could afford him. In 2024, after deposing his 500th hospital administrator who couldn’t recall whether patients were people or “billable encounters,” he sold his practice, moved to Oaxaca, Mexico, and now receives all his medical care from a system that—despite its flaws—still believes doctors should be allowed to practice medicine. He lives with two rescue dogs and a deep appreciation for physicians who haven’t been broken by spreadsheets.

He can be reached mañana.

DISCLAIMER: This is a work of satirical fiction. “The Medical Factory Without a Name,” its executives, and all events described herein are entirely fictional. Any resemblance to actual healthcare systems, living or dead administrators, or real institutional policies that prioritize liability over patient care is purely coincidental and almost certainly not actionable. Probably. Let’s talk tomorrow.

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The Last Hospital in America

The Last Hospital in America

By Omar Nabil Metwally, M.D.

13 January 2026

* * *

The Hospital That Was

I have a long-standing personal connection to this hospital. Over the decades, I watched it change names through a series of corporate mergers and acquisitions that made a lot of people rich—none of them the nurses, technicians, and doctors actually caring for patients and generating the revenue.

Despite the name changes, the hospital remained a cornerstone of our community, a safety-net hospital serving one of the most diverse patient populations I’ve ever seen. People from every walk of life came through those doors knowing they would be cared for. I treasure the encounters I’ve had with refugees, machinists, woodworkers, and factory workers among many others over the years.

My family and I used to visit on my days off. We’d see colleagues and friends, take photos with the toy bear in the lobby, and I’d work in the hospital library before it was converted into nursing offices and all the books were thrown away to make space for the ever-expanding corporate healthcare machinery.

I spent seven years as a practicing internal medicine physician there. It has been good to me. The hospital gave me the chance to care for people who really needed the help, to meet so many different people who’ve taken such diverse, interesting, and oftentimes difficult paths in life. It also gave me a respectable title, a parking spot, and the dignity of knowing I was doing something useful for others.

Today was my last day.

The Patient

The patient is an older man with schizophrenia who presented to the hospital with gastrointestinal hemorrhage—internal bleeding. He has almost no medical literacy and, due to his psychiatric condition, was lacking decision-making capacity. He was pending formal psychiatric evaluation to assess his competency.

When I reviewed his morning labs, his hemoglobin was 6.6.

For context: normal hemoglobin ranges from approximately 12 to 16 g/dL. A hemoglobin of 6.6 in a patient with active GI bleeding, particularly someone having active chest pain as was the case here, is a medical emergency. The patient needed blood. Immediately.

I placed an urgent order for blood transfusion.

The Refusal

Later, when I rounded on the patient, I discovered that the blood transfusion had not been performed.

I spoke with his nurse and asked why my order had not been executed. I explained clearly: this is a medical emergency. This patient needs blood transfused immediately.

Her response: I needed to obtain consent from the patient myself. This was, she said, hospital policy. From a patient who answered all of my questions with:

“I want to eat. Give me food.”

In seven years of practicing medicine at this hospital, I had never once been asked to personally consent a patient for blood transfusion. This is routinely performed by house officers or nurses, countless times per day across every hospital in America.

I asked the obvious question: Why are you refusing to transfuse someone who has questionable decision-making capacity and who urgently needs a blood transfusion?

I explained again that the patient lacked the capacity to consent. He was pending formal evaluation by a psychiatrist, and numerous colleagues had documented similar concerns about his capacity. As the attending physician and the one who ultimately bears responsibility for his fate, I was standing by his bedside and doing everything in my power to kick common sense into senseless corporate drones who have long ago lost respect for human dignity and life. Or perhaps they never had a chance to cultivate this quality in the first place. This was precisely the kind of situation where medical professionals are expected and entrusted to act in the patient’s best interest—and to absorb all the heartache and legal liability—while the Chief Medical Officer (a Caribbean medical school graduate) and the Chief Executive Officer (a nurse who has not touched a patient in decades and who is no more qualified to place orders than the CEO of an airline company is to fly a jumbo jet) count their cash and equity.

The nurse’s response:

“I have a family to feed, and I don’t want to lose my job by violating hospital policy.”

When a nurse’s first thought during a medical emergency is her employment status—when fear of administrative punishment outweighs fear of a patient dying on her watch—something has gone fundamentally wrong. Not with the nurse. With the system that created her fear.

The Exchange: A Real-Time Record

I contacted the Chief Medical Officer and explained the situation. I told him I was horrified that a floor nurse was more concerned about offending hospital administrators and losing her job than she was about watching a patient exsanguinate per rectum under her care. A patient whose physician had placed a transfusion order hours earlier and drove to the hospital to re-deliver the order face to face with a burnt out nurse and executive suite that would do humanity a favor by running a casino instead of a medical facility.

What follows is the text exchange, preserved in screenshots, that captures what happens when corporate healthcare confronts a dying patient.

Tuesday, January 13th. 3:20 PM. The patient is bleeding internally. His hemoglobin is 6.6—less than half of normal. He has chest pain. He cannot speak coherently. I have placed an order for an emergent blood transfusion. The nurse has refused to administer it. I pick up my phone and text the Chief Medical Officer:

“Dr. [CMO], pt in [room number] is apparent incompetent and needs emergent blood transfusion but RN is refusing.”

“She seems more concerned about not getting in trouble with hospital administrators than doing the right thing and saving a life.”

“I’m not sure who to report this to but this is unacceptable.”

I wait. The patient continues to bleed. One hour passes. Then another seven minutes. Finally, at 4:27 PM—sixty-seven minutes after my initial message—the CMO responds. Not with urgency. Not with concern. With policy:

“Nursing cannot do consents for transfusions. They can have the patient sign the form, but it can only be done after the physician obtains consent from the patient. You can speak to the patient with the nurse’s assistance and with her present over the phone.”

I reply immediately:

“The patient is incompetent.”

“It’s urgent.”

Then, as the absurdity of the situation becomes clear:

“The nurse has to use her brain. This is ridiculous. The man is hemorrhaging.”

“The day people are more worried about hospital policy than saving lives is a really sad day for healthcare.”

“I’m disappointed, Dr. [CMO].”

The CMO’s response was three sentences:

“Then you need to speak to the DPOA. She cannot seek approval. It’s a policy. Sorry.”

Sorry. A single word of pseudo-empathy appended to a directive that was impossible to follow.

Because there was no DPOA. The patient had no durable power of attorney—a fact clearly documented in the medical record by other members of the care team. The CMO was telling me to contact someone who did not exist.

When I pointed this out, the CMO offered another bureaucratic workaround:

“If you cannot call the DPOA then the House officer can do it for you.”

My final messages to the CMO abandoned any pretense of professional courtesy:

“Thanks for your help.”

“How much do you get paid?”

“What kind of CMO are you?”

The CMO—a physician by training, bound by the same oath to do no harm—sided with the nurse. He told me this was hospital protocol. A man bleeding to death in a hospital bed was less important than the chain of command and an organization founded on conflicts of interest.

The CEO

I then contacted the hospital’s Chief Executive Officer. I repeated everything. I told her plainly: this is not a company. This is a hospital. First and foremost, we are here to take care of human beings. Whatever policy is preventing this patient from receiving the blood he urgently needs is either being misunderstood or is a policy that warrants explanation.

Her response:

“We’ll talk tomorrow.”

Tomorrow. As if hemorrhage operates on business hours.

I told her: Just make sure the patient gets blood tonight. We can talk tomorrow, God willing.

That was my last communication with the hospital.

The Cover-Up

But the institutional betrayal didn’t end there.

I consulted a psychiatrist that same day to formally assess the patient’s decision-making capacity—a reasonable clinical step when capacity is in question. This is how medicine is supposed to work: when there’s doubt about a patient’s ability to make decisions, you get a specialist evaluation.

Hospital leadership blocked that consultation.

Instead, the CMO—going behind my back—arranged for a different psychiatrist, one I had never heard of and never seen, to evaluate the patient and attest that he was competent. Then, for good measure, the CMO got a resident—an unlicensed physician still in training who is supposed to be taking orders from me—to write a note that same night documenting that the patient was fully competent to make his own medical decisions.

Let that sink in.

An attending physician since 2017 with seven years of experience at this hospital, who had examined the patient at bedside daily, who had documented the patient’s inability to form coherent sentences, who had placed urgent orders to save his life—was being contradicted by a trainee’s documentation produced at the direction of hospital administration.

The move was surgical in its cynicism: undermine the attending’s clinical judgment and credibility while creating a paper trail that protected the institution. If the patient died, the chart would show he was “competent” and had “refused” care. Much easier than strapping him to a hospital bed and transfusing him against his will. The physician who tried to save him would be the outlier.

“The lengths they went to to cover up their mistake and gaslight me is incredible.”

What This Is Really About

A man with schizophrenia—vulnerable, lacking the capacity to advocate for himself, bleeding internally—was denied a potentially life-saving blood transfusion because hospital administrators have created an environment where nurses fear paperwork violations more than they fear a patient dying on their watch.

Cover-your-ass policy is official hospital policy.

The Chief Medical Officer, whose duty is to ensure quality patient care, sided with policy over the patient.

The Chief Executive Officer deferred the conversation to tomorrow—as if internal bleeding would politely wait for the next business day.

I became a physician to serve humanity and save lives. I did not become a physician to be a corporate drone, to be dismissed by corporate drones, or to stand helplessly while patients suffer the consequences of administrative cowardice dressed up as protocol.

A Note on Policy

Informed consent is a vital part of medicine. It protects patient autonomy. It is a right.

But every hospital in America recognizes exceptions for patients who lack capacity to consent and face medical emergencies. This is not a gray area. This is standard of care. When a patient cannot speak for themselves and will die without intervention, physicians act. That is the job. That is the oath.

A policy that prevents life-saving treatment for an incapacitated patient is not a policy—it is malpractice institutionalized.

To The Hospital

You were a place where families in our community came to be healed, where we took photos in the lobby, where the library had books and medical students and residents, and the hallways had heart.

Now you are a place where nurses say “I have a family to feed” while a patient bleeds, and executives schedule meetings to discuss why doctors are upset about it.

I don’t know what you are anymore.

But I know what you’re not.

You’re not a hospital. Not tonight.

The Bigger Picture

If you or someone you love has ever been a patient at a hospital, this story is about you.

It is about what happens when healthcare systems prioritize liability over life, when corporate culture infects medicine so deeply that a nurse’s first thought during an emergency is her employment status, and when the people at the top of the chain hear “this patient may die tonight” and respond with “let’s talk tomorrow.”

All that’s left in America is medical factories where health administrators have free reign to practice medicine without a license, using licensed doctors as liability-laden proxies.

This is one story. There are thousands.

* * *

Dr. Metwally is a licensed, board-certified Internal Medicine physician in good standing, a proud graduate of the University of Michigan and the University of Michigan Medical School. He has never been named in a malpractice lawsuit. He practiced internal medicine at this hospital for seven years. This writing does not reference the author’s alma mater.

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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.