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On Professionalism: A Dropped Towel and Feedback in Medicine

A Reflection on Feedback

By Omar Nabil Metwally, MD
Friday, October 9, 2026

The operating room is as I remember it. The retirement is imagined.

I. The Gift

One of the most valuable things I took from medical school was feedback. An immense amount of it. Feedback on my presentations, my notes, my knots, my differential, my tone, the way I held a retractor, and the way I held it after being told how to hold it.

More valuable still was the humble art of receiving it. You nod. You say thank you. You go home and get better. Medicine runs on this arrangement: you are corrected for about a decade, and you learn to treat every correction as a gift, including the ones that arrive unwrapped.

What nobody mentions is how rarely the current reverses. As a student, almost never. Later, as a resident or as faculty, every once in a while someone hands you a form and asks what you think.

II. The Form

I was remembering one of those forms: my exit interview from the University of Michigan Medical School. The school wanted to use it as an opportunity to improve, as it is always trying to do.

An aside before I go on. I can write this story because I think Michigan Medicine truly does set the bar for quality of healthcare in Southeast Michigan. This is by no means a rant. It is a personal reflection, thinly wrapped as an offer of constructive feedback. It was the only wrapping paper I had.

The form had a section on bullying and harassment. It gave me about three lines.

III. The Towel

During my surgery rotation, I dropped a towel on the operating room floor. It left my hands and went to the ground, the way towels do.

The scrub tech noticed. He was a heavyset older white man, and he had clearly been noticing towels for a very long time. He pushed me and said:

“Did you just drop a towel?”

“Yes, sir?”

I said it with the intonation of a question, because I was anticipating his next sentence. I expected to be handed the opportunity to say: I apologize, sir. Let me pick it up and scrub back in. That was how feedback had always worked. Observation, correction, gratitude.

Instead he told me:

“If you drop one more towel, I’m going to rip your balls off in front of all these women and throw them in the trash.”

IV. The Assessment

I have had fifteen years to review this feedback, and I want to be fair to it.

It was timely, delivered within seconds of the event. It was specific. It was actionable: one more towel. It named an indication, a procedure, an audience, and a disposal plan. To this day it is among the most complete operative plans anyone has ever presented to me in an operating room.

My only notes are technical. The trash is the wrong receptacle; that is what the red bags are for. No consent was documented. There was no time-out.

I wrote none of this on the form. I had three lines. I narrated a brief summary of the incident and moved on to the next question.

V. Fifteen Years Later

Thirteen years later. Actually, more like fifteen. I am an attending physician now, and it is interesting to hold this story up to the present light.

We live in a day and age of hypersensitivity. Anaphylactic sensitivity, even, where political correctness is concerned. To be fair to the immune system, anaphylaxis is a reaction to something: in this case, an extremely polarized, energized, fired-up world. The response is outsized. The allergen is real.

I am not sure what would happen if such an incident took place today. I would rather not even think about it. I suspect it would take more than three lines.

VI. Urologists Without Borders

Instead, I think about him.

I imagine him fifteen years on, comfortably retired, well pensioned by the university or by the union or, knowing him, by both. I imagine that retirement did not suit a man of his energies, so he volunteered. The organization is called Urologists Without Borders. It travels to war zones. He is its volunteer urology tech.

Afghanistan. Ukraine. A tent, a generator, a tray of instruments laid out with frightening exactness. I imagine the young surgeons adore him. I imagine that nobody in that tent has ever dropped a towel, and that nobody can quite remember why.

I imagine he has spent his retirement patiently helping to put back what he once proposed to remove. He is very good at it. Nothing goes in the trash that does not belong there.

And I imagine a local medical student, hands shaking, letting a towel slip. He looks at the towel. He looks at the student. He bends down, at his age, with those knees, and picks it up himself.

“Happens,” he says.

That is the whole fantasy. It is not revenge. I checked.

VII. The Closet

One more thing. The incident gave me a lot of food for thought. It really stoked my curiosity about a career in surgery, and in medicine in general.

I used it as an opportunity to learn, and to think carefully about whether I wanted to start my residency immediately or, alternatively, move into my close friend’s closet in his San Francisco studio apartment.

I chose the closet. I lived in it for a year, and we started our first company there. Then I did, eventually, go to residency.

Bottom line: looking back, no regrets. I would go back to San Francisco in a heartbeat. Nobody in that closet ever pushed me, and I could drop whatever I wanted.

VIII. On Professionalism

So this is a reflection on giving feedback, which turns out to be harder than receiving it. Receiving takes humility. Giving takes something more: you have to believe that the person on the other end is capable of being better than their worst sentence.

I believe that about him. I would like to think someone believed it about me, on the day I dropped the towel.

Professionalism is not the absence of dropped towels. Towels get dropped. It is what we say next, and that is the humane and human part, the part that brings us together as people and as professionals.

So, sir, if you are reading this from a tent somewhere: thank you for the feedback. I have implemented it. I have been very careful with towels ever since.

Yes, sir?

Addendum

This essay has since been submitted to JAMA, to NEJM, and to all the big ones. In the version of events I prefer, every one of them published it.

So picture a Sunday in San Francisco. A group of retired surgeons is having brunch. The journal is on the table, the physical one, on actual paper, passed from hand to hand between the eggs and the sourdough.

They read in silence, the way surgeons read, which is quickly and with visible disapproval.

Then one of them puts the magazine down and says, in a high-pitched Mickey Mouse voice:

“I know exactly which scrub tech he’s talkin’ about.”

A chorus of Mickey Mouse laughs goes around the table. Nobody drops anything.

The recollection is mine. The retirement and the brunch are imagined, as is the publication, and any resemblance of Urologists Without Borders to a real organization is coincidental.

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The Match

A sequel, with one interruption

By Omar Nabil Metwally, MD

First published 11 October 2026

I. The Review

My last essay ended with a census of my readership: North Korea, Syria, a pirate ship off the coast of Yemen, and ten or twenty Chinese Googles.

I can now report a human. His name is Ali. I sent him the link at night, and the next afternoon he sent back a review. He loved it. He hadn’t realized the interviews are all done on Zoom now. What a loss, he said. Then he thought about it some more: although, he guessed, it was expensive.

The AAMC needed a survey to get there. Ali needed four sentences.

My wife’s position is unchanged.

II. The Gunner

Ali thought it was a loss, so I told him what we lost.

Every medical school class has a gunner. For the pirates: a gunner is the student who treats medical school as a contest and intends to win it. I say this with respect. A gunner knows your patient’s potassium before you know your patient’s name.

A classmate of mine at Michigan wanted dermatology. Dermatology is about the hardest residency to get, for reasons every doctor understands: the pay is good, the hours are sane, and skin rarely has an emergency at 3 a.m.

He took no chances. He applied to fifty programs and flew to every one that would have him.

III. The G-Wagen

This was the old way. Every invitation meant a plane, a hotel, and the suit.

He paid the application fees. He paid Southwest. He paid Spirit. He paid a series of hotels selected for price.

By my estimate he spent a G-Wagen’s worth. I have no evidence of the G-Wagen. I had no evidence of the yacht either, and I stand by the yacht.

For the same money he could have bought the G-Wagen and driven it to the interviews. He would have pulled up to every dermatology program in America looking like a man who had already finished one.

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

IV. The Match

Residency is decided by a computer. You rank the programs. The programs rank you. On a Friday in March the computer reads both lists and tells you where you live now.

The computer considered fifty programs, a G-Wagen’s worth of travel, and every city Southwest serves. It sent him to the University of Michigan.

He was a medical student at the University of Michigan. He was already there. He could have walked.

I know the route. I walked it once, in a black suit.

I would like to feel superior about this. But I flew all over the country for medical school interviews, got into the one school I could walk to, and declined the rest. I did the same thing. He did it in a nicer car.

V. The Closet

I have never written about my own Match Day.

I did not want to go to residency. I have said elsewhere what I wanted, which was to start a company out of a childhood friend’s closet in San Francisco. He’s the only person I’ve known that I can sincerely still call a friend even after starting a company together, spending a year coding shoulder to shoulder during most of our waking hours, while also sharing rent for studio apartments in SF and NYC. I decided to take another “gap year”, which turned out to be the start of a career in gap years, after seriously considering a career in surgery during a mind-changing medical school surgery rotation (that deserves its own story).

The computer does not match to closets.

I did not have the courage to submit zero applications. That would have been obvious. So I applied to four programs in a specialty I had no interest in. I chose radiology. Although I admire visual art and consider myself someone with decent aesthetic taste, my mind tends to reach first to text and numbers when solving a problem before taking a visual approach.

I put on the black suit and interviewed at all four, with no serious intention of attending any of them. My classmate wore the suit for jobs he wanted. I wore it for four I did not.

In the end I decided to hold off on residency for at least a year. It turned out to be a year.

We all carried pagers then, the size of bricks. I once dropped one in the toilet in University Hospital and was under the impression that I had to fish it out and return it to security in order to be issued a new pager. But that deserves its own story too. Anyway, I knew what would happen when the algorithm finished its work. Everyone who matched would get a page congratulating them. Everyone who did not would be summoned to the dean’s office, slapped on the ass, and hustled into an unfilled residency spot in a specialty that may or may not be related to the applicant’s original interest. Bottom line is, you have a chance to redeem yourself and eventually become a licensed physician in a residency program.

I am no idiot. I knew what was coming. An email arrived silently in my inbox, telling me that I had not matched. Surprise, surprise. It was the inevitable outcome of my own making.

I turned off my pager and my phone. Then I did the only thing I could. I celebrated wildly with my friends, hugging and kissing, as though I had just landed a dermatology residency at an academic medical center with floors of perfectly reflective marble, and where the waiting lists are so long that patients perish outside on the front steps waiting for their first appointment. YES WE DID IT!!! I screamed in feigned ecstasy.

After about five minutes of celebrating, the receptionist huffed up the stairs to the small windowless room where my cohort of medical students was huddled.

“Omar, honey? You didn’t match. You need to come to the dean’s office, honey.” I quickly avoided eye contact with all of my classmates and darted to a remote bathroom that I reserved for emergencies like these.

My digestion is, overall, OK. On that particular day I made my way quickly to a bathroom deep in the bowels of the Medical Science II building and engaged in a continuous, fifteen-minute episode of watery diarrhea. It was catharsis in a gastroenterologic sense. The whole time I was trying to silence my pager. I had turned it off. It kept notifying me that I had not matched, even as I ripped out the AA batteries. I prayed that the woman who had huffed her way through a mile of indoor med sci labrynths wouldn’t track me down by my scent and walk into the bathroom. Omar, honey? I could imagine her  voice echo in the bathroom.

To make a long story short, I ended up learning to write iOS apps the old-fashioned way, which is a human actually writing the code. I had help from a friend, the only other physician coder I know. He is also a University of Michigan Medical School alumnus, an electrical engineer, and one of the most gifted programmers I know. He donated his time to meet me in cafés around Parnassus and in the UCSF medical library, where he helped me debug my GET and POST API calls. I owe him, at  least, a great deal of gratitude for all that time and help.

I did that for as long as I could, which was one year after medical school. Then I needed a paycheck, and I enlisted as a human battering ram for a local internal medicine residency program, where I met some of the most uniquely unforgettable and gifted people I’ve known: at St. Mary’s Hospital in San Francisco (now UCSF Health) and later at Highland Hospital in Oakland.

I am an internal medicine physician.

VI. Portland

An interruption.

This just popped into my brain.

Later I did it again, applying for a clinical informatics fellowship at Oregon Health & Science University. It is a  forward-looking university in one of my favorite cities. In reality, I ended up choosing UCSF. I was lucky enough to have many great options. In a parallel universe I went to Portland. The memory of a bright morning ride on the Seilbahn (Portland aerial tram) is a happy and lasting one.

I finished my shift at the county hospital in Oakland at 11 p.m. I got in my car with my white coat still on, drove to Oakland International, and flew to Portland. I checked into a hotel room that cost between $250 and $300 a night and slept in it for about two hours. That is roughly $140 per hour of sleep.

The morning after the interview I woke at 3:30 for the flight home. I woke with the hardest direction I have ever had. I am dictating this part, and the software has chosen the word direction. I am leaving it. It was the ordinary morning kind. Only the hour was unusual.

At security the scanner beeped. The TSA agent pointed to his screen. It showed the outline of a person, and on the outline, over my direction, a large red dot.

“I’m going to have to pat it down,” he said.

I was patted down without objection or resistance. Then I was on my way to the gate, to sip Portland-roasted coffee and wait for my flight back to Oakland.

Since then, when I go through airport security, I put my hands at my waist where they are clearly visible and ask the agent: do you need to pat me down?

Years later I told this to my family. Half of them are physicians. The other half are lawyers. My father snorted an insolent snort and said the TSA guy probably liked it.

I thought: he better have.

What was I saying?

VII. The Loss

So what did we lose?

Today’s gunner applies to fifty programs from his apartment. He does fifty interviews in one chair. On the screen there is no stool, and everyone is the same height. The camera shows him from the chest up. I was seen on a screen once during an interview trip, and the framing was different.

He spends nothing. In March the computer tells him he is staying where he is, and he has gone nowhere to find that out.

This is better. For decades we sent applicants around the country in black suits, on borrowed money, so that a computer could tell some of them to stay put. Ninety percent of applicants wanted the option of skipping it. I would have wanted it too.

The only thing lost is the story. Nobody pats today’s applicant down. My classmate has a story with fifty cities in it, and he paid a G-Wagen for it. I have Portland, and I paid for that too. That is experience.

His story cost me nothing. I just know the guy. That is reference.

VIII. Intellectual Property

I ended my message to Ali with a warning. If he writes a story about this before I get around to telling it, I’ll sue. I’ll sue him, and I’ll sue my classmate. For plagiarism.

I see the weakness in the case against my classmate. It’s his life. He lived it first, at great expense, and he has the receipts.

My position is that he only lived it. I’m the one who told somebody.

IX. Coda

The stopwatch is still running.

Experience is airport security with a 3:30AM direction. A machine can describe one. It has never been patted down for one.

Reference is a man who flew to fifty cities to end up where he started. I didn’t have to make him up.

Thank you for the opportunity.

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Northern by Nature

So this is the life — when you drive north on a dirt road in Michigan until houses disappear and your signal drops. You buy a map from a woman with a family name as Finnish-sounding as every other town on the Peninsula. You roast meat over fires smuggled from Prometheus to cavemen to modern man, sleep beside brothers, the fire crackling, the smell of birch, and you bandage the day’s wounds, each one the opening line to a great story.

So this is the life — when you wake to silence beneath a canopy of stars and planets you’ve neither seen nor dreamed, everywhere glimmering and shimmering millions of light-years and lifetimes ago, and in the stars you draw faces of people you can’t seem to forget.

So this is the place — where the glaciers retreated, and there, on the shore of that lake, painted rocks play time-lapse video of a world that can’t stand still, not for an Augenblick. The glaciers peel back earth like scabs. Minerals seep. The sun rises as soon as it’s set. Stars flirt with Venus and Mars. One day the sun shines, the next the snow falls, blanketing the same forests where the people before us hunted game, made clothes of hide, concocted herbal potions, sung war songs and rain songs, songs of happiness and grief, named the Great Spirit in every stone and leaf.

So those were the days — when stars turned men into poets and prophets, words uttered beneath the cosmic canopy wafted as lightly as waterborne winds, yet strong enough for a species to climb them to illuminated heavens.

1 June 2014
Pictured Rocks, Michigan

Image

 

[Ice on Lake Superior in June — still couldn’t resist swimming in it]