Posted on November 6, 2026 by omarmetwally

Notes toward an advance directive

Omar Nabil Metwally, MD

I have started planning my death the way other people plan a kitchen remodel: with a folder, a rough budget, and a growing list of contractors I will never hire again.

This is not morbid. I want to be clear about that, because my family will read this and worry, and my wife will not read it and worry anyway. It is the opposite of morbid. It is the single most practical thing I have done since I learned to check the expiration date on the milk before buying it. I am a physician. I am about fifteen years out of medical school. I have spent a measurable fraction of my adult life inside American hospitals, and I have come out the other side with one conviction so clean and so bright that I can hold it up to the light and see no flaw in it anywhere:

Never again.

Let me tell you what a hospital is, in case you have only ever visited one, which is like saying you have visited the ocean because you once stood in a parking lot near it.

A hospital is a building in which it is impossible to sleep. The bed inflates and deflates itself on a schedule known only to the bed. Something beeps. Something else beeps in answer, and the two of them carry on a conversation across the hallway all night like dogs. At four in the morning a kind person arrives to take your blood, not because anything will be done with the result before nine, but because four is when the blood is taken. A television bolted to the ceiling plays a cooking show no one chose. The hospitalist changes every seven days, like a weather front. The nurse is excellent and has eight other patients, three of whom are screaming and one of whom is you. On day three someone orders a scan to explain a finding that was caused by day two. On day five you leave with a discharge summary longer than the Finnish constitution and a new diagnosis you did not have when you arrived.

And then, on the far side of all of it, there is a person whose job title is Risk Management, who has never touched a patient and whose entire function is to make sure the building is never the one holding the bag. I have written elsewhere about the sixteen hours. I will say only this: the day you start wishing broken hips on risk managers, out loud, in a family group chat, is the day you have officially graduated from American healthcare. There is no ceremony. You just know.

Nobody chooses any of this. It accretes. It is the clinical equivalent of a junk drawer, and the horrible part, the part that took me years to admit, is that I helped build it. I have ordered the four a.m. labs. I have written the summaries. I have stood at the foot of the bed at seven in the morning and said “we’re going to keep you one more night, just to be safe,” and I meant it, and I was wrong.

Here is what fifteen years taught me, and I am giving it away for free, which is already more than the system has done for anyone: the surest way to stay well, physically and mentally, is to stay out of the hospital. Too much of what happens inside one is where people go to get sicker, suffer, and die. Not always. Not everyone. I still send patients there every week and I will keep doing it, because there is a real category of problems for which the alternative is worse, and when you are in that category you go, and you go now. That is not what this essay is about. This essay is about everything else, which is most of it, and about one body in particular, which is mine. Nothing here is advice. It is a man describing his own exit.

And when I truly do need healthcare, the kind where a doctor sits down, I will book a flight to a country that has an actual working system. I have been on the receiving end of that kind of care, and I did not know what to do with my hands. Someone looked at me. For minutes. There was no portal. There was no “I’m going to step out and you’ll hear from someone.” I kept waiting for the catch and the catch was the bill, which I paid out of pocket with the kind of money I keep in the glovebox for parking.

When I was in my twenties I spent a summer in Finland measuring trees, and I came away with two permanent injuries: a lifelong respect for a country that treats a sauna as public infrastructure, and the inability to ever again find it normal that a sick person should have to fight. In Finland the hospital was a building where sick people went and then, after a while, left. That is the whole trick. We have made it sound exotic.

So here is the plan. When the diagnosis comes, and it will, I have read the actuarial tables, this is what I intend to do, in order. I am talking about the end, the real one, the kind every clinician recognizes from across the room. Not the first chest pain at fifty. I know the difference. It is the one thing the training is reliably good for.

I will not be admitted. I will be a visitor. I will keep my coat on, the way you keep your coat on at a party you are planning to leave. If anyone says the phrase “just to be safe,” I will understand it as the sound of a door closing, and I will walk through it in the other direction.
If it is the fast kind, the stroke or the heart attack, I will crawl under a warm blanket and thank God, sincerely and for the first time in years, that I do not have to die in a hospital. A blanket. Think about how low the bar is. Think about what it says that the blanket wins.
If it is the slow kind, I will go home. I have a garden. I grow tobacco, which is a wonderful plant to grow when you have decided to stop pretending you will live forever, and tomatoes nobody asked for, and I have a four-year-old who narrates all of it. There is a puppy. There is no television bolted to the ceiling. Nobody comes at four in the morning except the puppy, and he does not want my blood, he wants the yard.
I will book a flight. Somewhere a doctor still sits down. I am not particular about which somewhere. I have a short list, and the list is organized not by survival statistics but by a single question: in this country, when you are dying, does anyone look at you?
I will say no. This is the hard one. Physicians are terrible at it. We know exactly which interventions buy a week in exchange for the week, and we accept them anyway, because saying no in front of your colleagues feels like quitting the team. I am putting it in writing so that I cannot pretend later that I didn’t know. I knew. I know now. No.
I will end in a sauna. If it is up to me, and the entire purpose of this document is that it should be, then it ends in a sauna, at a temperature that would alarm a cardiologist, with a lake outside doing what lakes do, and someone I love sitting on the lower bench complaining that it is too hot. That is a death. The other thing, the inflating bed and the beeping and the cooking show, is a billing event.

My wife, who is the smartest person I have ever known, has never read anything I have written, and she is not going to start with this. Which means my advance directive will be executed by someone who has not read it. I thought about this for a long time and decided it was fine. That is how most of American healthcare is practiced, and I would hate to be inconsistent at the very end.

So I’m saying it here, out loud, where my siblings will find it and forward it to her with the subject line “did you see this”: When it’s time, don’t take me to the hospital. Take me to the airport.

STAT. It’s hospital for “now.” It is the only word from the place I intend to keep.

Posted on November 6, 2026November 6, 2026 by omarmetwally

Risk Management is Home Sleeping

By Omar Nabil Metwally, MD

Earlier this week Oskar wrote up Russ Pelletier’s theory of cricket fighting: you catch a calm insect, tie a strand of your own hair loosely around its neck, shake it until it’s furious, and drop it into an arena with another insect prepared the same way. Russ was describing malpractice litigation. He thought the cricket was the doctor.

Russ has never been a patient at a Level I trauma center. I’d like to submit the following chart for his review. All times approximate. Vitals stable throughout.

The secret to American healthcare is this: if you want to be healthy, physically and mentally, stay out of the hospital. American hospitals are where people go to get sick, suffer, and die. And if you really do need healthcare, book a flight to a civilized country that has an actual working healthcare system. STAT.

15:00

Patient arrives. Polite. Professional. Shaved. Rolled in semi-conscious with pain and still says “thank you” to the greeter, which the greeter notes, since it’s rare. Patient has come to see an orthopedic surgeon about a hip, a thing he has been trying to do for months through the proper channels, and has concluded that the proper channel is the one with the ambulance bay. Patient is an internist of fifteen years and a graduate of this institution, twice, which he mentions to no one, because he assumes the building will recognize him on its own. The building does not. The building ties a loose plastic strand around his wrist and places him on a stretcher in a hallway, under lights calibrated for surgery, and walks away.

17:29

The hospital texts the patient. Unprompted. It says it understands waiting can be difficult, that the care team checks on people at intervals, and, in a sentence the patient will think about for the next eight and a half hours, “Please know we haven’t forgotten you.” Nobody had accused anyone of anything. The institution’s only spontaneous communication of the night was a denial of the thing it was about to do. The text closes with “Reply STOP to stop texts,” which is, across the entire night, the only exit the institution will offer. The patient does not reply STOP. He is afraid it will work.

18:00

Patient is making jokes about peristalsis. This is the first clinical sign. A man who arrived capable of small talk is now explaining to a group text that triage is a lumen and he is in the jejunum. He is holding a Whole Foods bag of his own MRIs on compact disc. He has been x-rayed again. He told the tech he was well done. Nobody charts this, because nobody is looking, which is the point of a hallway.

20:00

Patient has stopped reading and started listening, because in a hallway you don’t get to choose. He now knows the name, charge, and theory of defense of the man in handcuffs across from him. He has opinions. The deputies have a chair. More people are arriving in custody. The emergency department is beginning to resemble a precinct, except a precinct has a vending machine and we have a sign explaining why ours is out of order.

22:00

Patient has been shaken for seven hours. In cricket terms he is ready. In clinical terms he is “resting comfortably,” which is what you write about a man you haven’t seen. Patient is at this point quietly composing a proposal to convert the cardiovascular center’s glass atrium into a dispensary. He believes this would be the highest-value addition to the hospital. He has told a nurse this. She didn’t laugh, which he’s decided means she agrees.

23:59

A diet order appears. This is the first order of any kind on the patient. For nine hours he has been NPO, not for a procedure, not for a scan, not for anything, but because nobody wrote the sentence that would have let him have water. He has been fasting in preparation for nothing, which is a very pure form of fasting, the kind monks train for. He began asking for water around hour six. Each nurse, in turn, said she had messaged the doctor. There was no doctor. There was a future doctor, somewhere in the building, who would at some point be assigned, and the messages were accumulating in an inbox that did not yet have a person attached to it, like letters to Santa. By hour nine the patient’s mouth is parched and his urine is the color of a good bourbon, which he knows because he is an internist and because they’ve had him collect it. Nobody has looked at the cup either. A keystroke at midnight ends the fast. Nobody brings the water. The order was the point.

For the record, the texts kept coming, and together they form the only complete account of the night, because the robot was the one member of the care team who never stopped checking on him. An X-ray has been ordered. Complete your registration online (from a stretcher, with no water, one-handed, the other hand on a bag of CDs). You have been moved to room HF07/F7, which is a hallway, but a hallway with a room number, which is how a hallway gets billed. Erion has been assigned as your nurse. Grace has been assigned as your nurse. Grace; Sara has been assigned as your nurse. The nurses were assigned the way crickets are assigned: in rotation, each one shaken a little, none of them told why the box was there. At 22:42 a medical provider was assigned. At 23:46 a supervising physician was assigned. The future doctor had arrived, by SMS, seven and a half hours in. Nobody came to say so. The phone did.

At some point the patient texted the robot back. He typed the name of the nurse in pink, on the theory that the hospital’s most responsive employee might want to know. The robot replied: “We couldn’t process your request.” Which was, he noted, exactly what he’d been told in person, only faster.

02:00

Patient gets off the stretcher and walks to the clerk. He has three questions, in escalating order. Is there a physician on my case? Am I still in a hospital receiving medical care? Or is this a social event, and I was seated at the corrections table?

The clerk looks at the screen. The screen has the one thing worse than a bad answer, which is nothing. Patient has not been triaged, forgotten, or discharged. Patient has been set down. Somebody picked up the box eleven hours ago, put it on a shelf, and went to do something else, and the patient has been getting shaken by the HVAC.

02:03

A nurse in pink scrubs, who could not be older than the patient’s residency, makes a beeline across the nurses’ station to raise her voice at him. Not at the man in cuffs. Not at the clerk with the blank screen. At the cricket, for walking to the edge of the box. Nine hours lying quietly under the lights: unremarked. Thirty seconds standing at a desk: a situation.

This is not recorded.

02:04

Patient raises his voice back. Patient says a word. I won’t repeat it; it’s in the chart. It is, in fact, the only word from the entire night that’s in the chart. The provocation was spoken. The response was documented. That is how, between a hallway and a door, a man with a stable heart rate acquires a psychiatric diagnosis authored by the person who caused it.

Patient asks to speak with Risk Management. He is informed that Risk Management is home sleeping.

Risk, it should be noted, was not.

02:08

Security arrives. Two young men who look like my nephews. They are, without competition, the kindest people the patient has encountered since 15:00. They have clearly made this walk a hundred times and know before they arrive that “agitated patient” means a tired middle-aged man asking why nobody’s seen him. Nobody tied anything to them. Nobody shook them. They are the only two people in the department without a chart to protect, so they have room to be decent. The hospital has outsourced its kindness to security.

They turn on their body cameras. And so, eleven hours in, enough time to fly from North American to Asia, the first impartial record of the patient’s care is created, by accident, by the people sent to remove him. The footage does not contain 15:00 through 02:03. It does not contain the stretcher, the lights, the blank screen, or the beeline. It contains a man in a hallway being loud. Footage with no history, like a diagnosis with no history, is a very clean document. The camera turned on after the arena was finished with him and pointed at the cricket.

Patient feels bad for the guards. This is also not charted.

02:15

A room opens. Not because of the questions. Because of the mop. The room has a door. The door is the great luxury of American medicine: a place where you can’t hear what’s wrong with anyone else. The patient is placed inside it the way a bar at closing time places a man on the curb: lights up, bouncers out, the bartender who started it wiping down the counter like nothing happened. Last call for medical care. You don’t have to go home, but you can’t stay in the hallway.

An attending appears, a real one, and the patient’s main anxiety is that after eleven hours composing hospital satire in a hallway he no longer presents as a colleague but as an Internal Medicine Physician Emulator, and that the attending will conclude he’s a simulation. The attending asks how he can help. The patient says: I came here to see an orthopedic surgeon about my hip, and I’m not leaving until I do. The attending is dry about it. Everyone’s dry. Nobody’s had water since three.

03:00

A calm, sweet nurse takes over the patient’s care, after the fact, the way a cleanup crew takes over a parade. She asks if he has any feedback. He does. Constructive, even. Put cameras at every station. Big ones. In everyone’s face, nurses included, running all night. Then, when an incident happens, you’ll have footage of the events leading up to it, which is the part that would let you prevent the next one, instead of two body cameras aimed at the customer’s response. She nods and writes it down. The patient suspects it goes in the same inbox as the water.

07:08

The phone buzzes. “A consultation has been ordered.” Sixteen hours after the greeter, the sentence the patient came for. He reads it twice. It doesn’t say which consultation. It doesn’t have to. Reply STOP to stop texts.

Discharge

Diagnosis resolved. Not treated; resolved, the way a hair resolves when somebody unties it. It will not be mentioned at discharge, and it will follow the patient to every emergency department he walks into for the rest of his life, where it will be read before his name, and he will be shaken accordingly. The footage is retained. The nurse’s last name is not released. Risk Management will review the incident at 9:30, over coffee, and conclude that the system worked.

Addendum, for Russ

Here is what the arena doesn’t tell you. The nurse in pink is a cricket. Young, shaken hard and early, and she crossed that station because something in her own hair got pulled. The clerk is a cricket with a blank screen. The nursing supervisor who eventually appeared is a cricket; she said so, more or less, with her face. The resident who finally came through the door is a cricket on hour twenty-something. Everyone in that building was tied and shaken by the same hand, and the hand was home sleeping.

Russ thinks crickets fight each other. They don’t. They get put in the same box and told it’s an arena. The only unusual thing about last night is that one of the crickets had spent ten years inside this particular building, walked in assuming it would know him, and stayed awake long enough to watch it not.

Nobody asks the cricket. But they do film it.

A note, before anyone forwards this to Risk Management

This is meant as reflection, not prosecution. Nearly every person I met in that building over sixteen hours was excellent. Truly, measurably above average: the techs, the clerk with the blank screen, the two security guards, the calm nurse who took the feedback, the attending who was dry with me because I’d earned it. Even the nurse in pink was good at her job; that’s what makes the beeline worth writing about. None of this is good cop, bad cop. There are no bad cops in this story. There is a box, and a hand that isn’t in the room, and a lot of very tired crickets being decent to each other at two in the morning, which is harder than it sounds and happens more than it should have to.

It’s early. We’re all tired. I’m writing this from a room with a door, in a hospital I’ve loved since I was eighteen, waiting for a consultation that has been ordered. If you work here and recognize yourself: thank you. If you run the place and recognize the hallway: that’s the part I’d like you to read twice.

And one ask, for everyone with a badge. Give the patient a break. You are in the position of power. You have the keys, the water, the chart, the cameras, and the door. The patient has a wristband and a paper bag. When he finally gets up and walks to the desk, he isn’t challenging you. He’s asking whether he still exists. The answer to that question costs nothing, and it’s the only thing in the building that does.

I know the argument. He raised his voice. He said a word. But think about who got to decide when the clock started. The patient was polite for eleven hours, and that counted for nothing, and then he was loud for thirty seconds, and that became the record. That’s not a judgment about him. That’s a description of power: the side that writes the note decides which thirty seconds matter. If the roles were reversed, if a nurse had been left in a hallway from three in the afternoon to two in the morning, without water, without a doctor, listening to custody cases, and finally walked to a desk to ask whether anyone knew she was there, every one of us would call her raising her voice reasonable. We’d call it the first sane thing that happened all night. The patient doesn’t get that reading, because the patient doesn’t get to write anything down.

Every hospital and clinic in America now has the sign. You’ve seen it. Threatening or abusive behavior toward staff will not be tolerated. I used to nod at it. I’ve had patients yell at me; I know what it protects. But read it again from a stretcher. The sign only faces one direction. There is no sign that says leaving a patient in a hallway for eleven hours without water will not be tolerated. There’s no sign that says crossing a nurses’ station to raise your voice at a man asking if he’s been forgotten will not be tolerated. There’s a text message that says we haven’t forgotten you, and then there’s the sign, and the sign is for him. An institution that posts rules for the powerless and texts reassurances to itself has told you exactly who it thinks the threat is.

So when the tired person on the stretcher finally snaps, the question isn’t what’s wrong with him. It’s what took him so long, and what you’d have done at hour six. Give the patient a break. He’s the only one in the room who can’t give himself one.

Go Blue.

Posted on November 5, 2026 by omarmetwally

The Nukes Are Falling

By Oskar Rausch, Civil Defense Correspondent (self-appointed), Former Cabin Mate and Sauna Buddy to the Editor

This is a work of satire and fiction. Any resemblance to an actual six-year-old is because all six-year-olds are the same six-year-old.

I. The Call

Gary Pelletier, fifty-one, of Osprey Landing (a community of distinction, per the sign), was on his patio at 4:22 on a Tuesday afternoon when he heard, through the vinyl fence, the following intelligence: “The nukes are falling! Everybody in the fort!”

The source was Mason Hendricks, age six, a boy Gary had always considered serious. Mason did not make things up. The previous July Mason had informed Gary that the lawn was lava, and Gary had walked out onto it barefoot to prove a point, and Mason had been correct.

Gary did what any citizen with a cordless phone and no dog in the fight would do. He called 911.

I have obtained the transcript. I have not obtained it legally, but I have obtained it in the sense that I was told about it in a sauna, which in my experience is the more reliable chain of custody.

“911, what is your emergency?”

“Yes, hi. I’d like to report that the nukes are falling.”

“Sir, where are you right now?”

“My patio. I can’t see them yet. But I have it on good authority.”

“What authority?”

“The Hendricks boy. Through the fence. He was specific. He said, quote, the nukes are falling, everybody in the fort, and then he made a sound like pshhhkkkrrrr, which I believe was the first one landing.”

“How old is this boy?”

“Six. But a serious six.”

“Did he say which nations?”

“He did not. But we can work it out. Russia holds roughly forty-five percent of the world’s warheads. We hold about forty-three. China’s at five and climbing. France two, the UK two, and then you’re into rounding error, Pakistan, India, Israel, North Korea, call it three percent between them. So if nukes are falling, there’s an eighty-eight percent chance it’s one of the big two.”

“Sir, did you just do that in your head?”

“I had it on an index card. I’ve had it on an index card since 2022. You think I’m the kind of man who waits for a six-year-old to tell him the nukes are falling before he looks into it?”

“Okay. So Russia.”

“Hang on. Hang on. That’s total stockpile. That counts the ones in storage, the ones waiting to be dismantled, the ones in a warehouse in Siberia with a tarp over them. If you count what’s actually deployed, loaded, pointed at something, ready to go on a Tuesday afternoon, we’re ahead. We’ve got more in the chamber than anybody.”

“Sir.”

“Ma’am, I think we’re being nuked by us.”

“Sir, I need you to—”

“I’d like to amend my report. I’d like to report a friendly fire incident. Is there a different number for that? Is that still you, or is that the Air Force, or is that just a letter to my congressman, because I’ve written him before and he sent back a photo of himself with a dog.”

There is a pause here in the transcript that the dispatcher later described, under oath, as “load-bearing.”

“Is anyone else in the fort?”

“Just him and a dog named Chicken Nugget. Which, if you think about it, is exactly who survives.”

“Sir, I’m going to go ahead and not dispatch anyone.”

“That’s fine. That’s your call. But I’ve already asked over the fence for a spot in the fort, and he said I have to be a Pokémon, and I said I’d be a Pokémon, so I’m covered. I just thought the rest of the county should know.”

“Which Pokémon?”

“I don’t know yet. A good one. One with a lot of HP. I’m fifty-one, I need the HP.”

II. The Response

Two officers were dispatched anyway, not because policy required it but because the dispatcher put the call on speaker and the shift sergeant said, “I have to see this.”

Officers Ruiz and Bramble arrived at 4:31 and found the situation substantially as reported. There was a fort. It was constructed of two patio chairs, a beach towel, and a pool noodle serving in a structural capacity it was not rated for. Mason was inside with Chicken Nugget, a dog of indeterminate breed and total conviction. Gary was outside the fort, standing at attention, holding a garden rake.

“What’s the rake for?” Ruiz asked.

“I’m a Pokémon,” Gary said. “This is my move.”

Mason emerged from the fort to brief the officers. His briefing, which Bramble recorded in his notebook and later could not bring himself to throw away, was as follows. The nukes had been launched by “the bad guys,” who were “over there,” indicated by a gesture at the Templetons’ screened lanai. Three had landed already. The swimming pool was gone. The shed was gone. The grill had been “melted into a different grill.” Survivors were to report to the fort, where there was lemonade, but only one cup, so they would have to share, and Chicken Nugget had already licked it.

Ruiz asked if there was anything they could do to help.

Mason considered this with the gravity of a man who has been asked to delegate during a crisis. He assigned Ruiz to “guard the lemonade.” He assigned Bramble to “watch the sky and say when.”

Bramble watched the sky for eleven minutes. Three times he said “when.” Each time Mason made the sound and Chicken Nugget barked once and everyone, including Gary, got down.

Bramble later told his wife it was the most useful he had felt on the job in nine years, and she said, “Honey, that’s very sad,” and he said, “No, you don’t understand, I was the one who said when.”

III. The After-Action Review

The Osprey Landing Homeowners Association convened an emergency session the following Thursday, as it does whenever anything happens or fails to happen. The minutes reflect three agenda items.

First, whether the fort constituted an unpermitted structure. (Tabled. The fort had been disassembled by bedtime, and the pool noodle returned to the pool, where it continues to float without incident.)

Second, whether Gary Pelletier had violated the community’s quiet-enjoyment covenant by summoning law enforcement to a residential block over “an unverified nuclear event.” Gary spoke in his own defense. He said he had heard a credible report of an incoming threat from a source with a track record, and he had escalated it through the proper channel, and he would do it again. He said the problem with this country is that nobody escalates anymore. He said everybody hears the kid through the fence and everybody goes back inside and finishes their beer. He said, “I am not that guy.” Several residents applauded, which the minutes note was “not procedurally appropriate but understandable.”

Third, whether the Hendricks family should be asked to keep Mason’s geopolitical announcements to an indoor voice. Mrs. Hendricks said she would take it under advisement. She then asked the board whether anyone present had, in the last decade, said anything as clear, as actionable, or as immediately heeded as “the nukes are falling, everybody in the fort.” The board had no response. The item was tabled.

IV. Sauna

I told this story to Omar on the top bench, where all stories are told, and I expected him to laugh, which he did, and then I expected him to stop, which he did not, not for a while.

When he finally wiped his face he said that Gary was the only person in the story who was doing it right.

I asked him to elaborate, because that is what you do on the top bench, you ask the other man to elaborate and then you suffer.

He said: a man hears a warning. He does not know if it is real. He does not have the training to assess it. So he picks up the phone and he tells someone whose job it is to know, and he tells them exactly what he heard, who said it, and how much he trusts the source. He does not sit on it. He does not wait to see if the sky changes color. He does not fill out a form and get a fax back in six weeks saying the nuclear event has been deemed not medically necessary. He calls. And when the person on the other end decides it is nothing, he says, that’s your call, and he goes and stands by the fort with a rake, because he has also hedged.

“I have patients,” Omar said, “who hear the kid through the fence for two years before they call anyone.”

I said I thought the piece was supposed to be funny.

He said it was. He said the funny part is that the dispatcher was right, and the officers were right, and the HOA was right, and Gary was right, and the only one who was ever actually in danger was the grill, which had been melted into a different grill, and nobody filed anything about the grill.

Then he poured water on the rocks, which is how he ends an argument he is winning.

I have since learned that Gary settled on Snorlax. I think that’s correct. A lot of HP. Sleeps through most of it. Wakes up when it matters.

FIN

Posted on November 3, 2026November 3, 2026 by omarmetwally · 1 Comment

The Cricket Breeders

By Oskar Rausch

Russ Pelletier is seventy-three years old, and he is the coolest man I have ever met who owns a Saab. He has defended doctors and sued doctors, sometimes in the same calendar year, and he regards this the way a fisherman regards switching from the river to the lake. He skis. He has a tattoo he will not explain. He takes a sauna the way the Finns do, which is to say silently, and this is how I came to know him: the two of us, strangers, sitting on cedar at a Lutheran retreat center in the Upper Peninsula, saying nothing to each other for forty-five minutes, which in Finland constitutes a friendship.

On the third day he spoke.

“Do you know about the crickets?”

I did not know about the crickets.

Russ had seen it on the Discovery Channel, late, on the kind of night when a man of his age gets up to use the bathroom and makes the mistake of walking past a television. The segment was about children in Vietnam. These were children who did not have iPhones or iPads or consoles. If they wanted to play a video game they went to a shop and paid by the half hour, like a parking meter, and when the half hour ended so did the game, whether or not you were in the middle of something. So mostly they did not do that. Mostly they fought crickets.

Here is the method, as Russ explained it to me, and as I have since confirmed with my friend Omar, who is a doctor and has seen it done, and who went very quiet when I told him why I was asking.

You catch a cricket. You pull a single strand of hair from your own head. You tie the hair around the cricket’s neck—gently, gently, because if you tie it too tight the head comes off, and then you have nothing, you have wasted a hair. Then you shake it. You shake the cricket around on the end of the hair until it is upset enough to show its fangs and open its wings, and when it is in that condition, trembling and furious and ready to kill something, you release it into the arena, where another child has done the same thing to another cricket, and the two crickets, who have no quarrel with each other and until ten minutes ago were both eating the same leaf, fight until one of them stops.

“I sat up in bed,” Russ said. “I said, out loud, to no one: that’s it. That’s the whole thing. That’s my career.”

He laid it out for me the way he lays things out for juries, with a long pause after every point so you can feel yourself agreeing.

The cricket is the doctor. The doctor does not know he is in a fight. He is eating a leaf. He is seeing twenty-six patients, of whom eleven are there for something that will resolve on its own and two are there for something that will not, and he is trying very hard to figure out which two. He has no quarrel with anyone. He went into this to help. That is the first and most important fact about a cricket: it would rather be in the grass.

The hair is the lawsuit. It is remarkably thin. It is made from the plaintiff’s own head—a real grievance, a real loss, a real strand of somebody’s actual life—and this is what gives it its strength, because you cannot argue with a hair. You can only be tied up in one. The children know that the tie must be gentle. Too tight and the head comes off, and a cricket with no head cannot fight, cannot settle, cannot be insured. A doctor who is destroyed outright is of no use to anyone. The art is in the restraint. You want him alive, and tied, and panicking.

The shaking is discovery. Russ was particularly pleased with this one. “Eighteen months,” he said. “Depositions. Interrogatories. You request every chart. You request his texts. You request the texts of the nurse who was on break.” You shake the cricket until he shows his fangs—which is to say, until he says something defensive in a deposition that can be read back to him later in a different tone of voice—and until he opens his wings, which is the moment he hires his own expert, who is also a cricket, but an older one, who has learned to fight for money.

The arena is the courtroom. The two crickets are the two experts. Neither of them has ever met the patient.

And the judge?

Russ smiled. In the dark of the sauna he looked like something carved. “The judge isn’t the judge,” he said. “The judge is the kid holding the money.”

Because in Vietnam—and here is the part the Discovery Channel got right and the law schools do not—the crickets were never the point. Nobody loved the crickets. The crickets were a medium. The point was the circle of other children around the arena, and the bets, and the way a half hour of someone else’s fight could be made to pay better than a half hour of your own video game. The children with the best crickets did not become wealthy. The children who ran the betting did.

“Contingency,” Russ said, and leaned back against the cedar, and closed his eyes, a man at peace.

I asked him what happens to the losing cricket.

He thought about it.

“Well, in Vietnam, nothing. It doesn’t die. People think they fight to the death but they don’t. The loser just—stops. It stops chirping. It turns around and walks to the edge of the arena and it won’t fight anymore, no matter how you shake it. You can tie a hair around it all day. Nothing. It’s done. It’s just a cricket now.”

He opened one eye.

“We call that early retirement. Or Florida. Or administrative medicine. I’ve seen a lot of them walk to the edge.”

And the winner?

“Oh, the winner goes right back in the box,” Russ said. “That’s the beauty of it. The winner proved he can fight. He’s worth more now. Insurable. Somebody’s going to want to tie a hair around that one.”

Omar, when I told him all this, did not laugh, which is unusual for him, because he laughs at almost everything, as a kind of medical necessity. He asked me instead whether the children in Vietnam ever felt bad about the crickets. I said I did not think so. I said they were children, and the crickets were crickets, and nobody had ever asked the crickets.

“That’s the part,” he said. “That’s the whole part. Nobody asks the cricket.”

Then he asked me how tight the hair has to be before the head comes off, and whether anyone had ever measured it, and I said I assumed that was the kind of thing you learned by doing, and he said yes, in his experience, it was.

Russ, for the record, is retired now. He does not keep crickets. He keeps bees, which he says is the opposite thing: thousands of them, all on the same side, and if you treat them well they make something sweet, and if you treat them badly they all come at you at once. He says he thought about going into that line of work instead, back in 1979.

“But there’s no money in bees,” he said. “Everybody knows what a bee is going to do.”

Oskar Rausch is Omar’s former cabin mate and sauna buddy. He has never been sued, tied up, or shaken, but he has been to Florida.

Posted on November 2, 2026November 2, 2026 by omarmetwally

Negligence by Policy

A Tale of Shared Accountability

This is a work of satire and fiction.

The best and most beautiful plants are fertilized with shit.

I. The Window

The waiting room of Quaternary Risk Management had fourteen chairs, a water cooler with no cups, and a television playing the system’s commercial, in which a woman jogged across a bridge at dawn while a voice said together eleven times. A banner read: Quaternary Health. The fourth level of care. Please complete the first three. Under it, smaller: One concern per visit.

Marisol Vega had one concern. It was thirteen years old and sitting next to her.

His name was Dante. He was playing Super Mario on his grandfather’s original Game Boy, the gray brick with the green screen. It was older than Quaternary’s electronic medical record and, unlike the record, had never gone down for maintenance. The volume was all the way up. He had been told about the volume. He had considered the information and declined.

Her complaint was on the form in block letters so there could be no confusion.

In 2013 I called Quaternary for a contraception appointment. The first available new-patient visit was four months out. I took it. By the time it came, it was a prenatal visit. I would like to know who decided four months.

The form had a dropdown for Nature of Concern. None of the options was “conceived.” The closest was Parking, which was at least where it had started.

II. The Wait

Four months was not a decision. That was the first thing she would learn. It was a template.

New-patient slots were made on one side of the four-foot gap in the belt and consumed on the other, and in between they fell. The ones that survived the crossing were released on the first of the month, at midnight, to whoever was holding. Marisol had held for forty minutes, the full length of the hold music, which had been shown in trials to resolve a third of all complaints without intervention. She had not been resolved. She had been given October.

Dr. Anjali Patel saw her. Dr. Patel was told at 7:58 that it was a contraception consult and at 8:04 that it was not. She found the heartbeat. She said, “Well. Okay. Let’s do this.” She wrote the prenatal vitamins and stayed eleven minutes past the slot, which the practice administrator flagged in her quarterly throughput review. It was the only part of the process that worked, and it was the only part anyone would ever be punished for.

III. The Liaison

At 9:15 a door opened and a man in a lanyard said “Vega?” the way you say the name of a dog you are not sure is yours. His badge said Patient Experience Liaison. He led them to a room with a round table, a box of tissues, and the word INTEGRITY framed over a photograph of a canoe.

“First, I want to thank you for sharing your experience.”

“I haven’t shared it yet.”

“And I want to honor that.” He found the date on the form and did the math. You could watch him do it. “So this is outside our standard thirty-day window.”

“By how much?”

“Roughly four thousand seven hundred days.” He said it kindly. “But I’d be happy to open a new case. Our next intake is February.”

Through the wall, Dante reached the underground level. The music changed. The liaison flinched.

IV. The Ecosystem

Here is what Marisol learned over the next three hours. You cannot sue Quaternary Health, because Quaternary Health is not, in the legal sense, a thing.

It is a care ecosystem. It is a family of brands. It is a nonprofit that owns a management company that contracts with a physician group that is an LLC that leases its doctors to a hospital that belongs to a foundation whose board meets in a city none of them live in. You cannot sue an ecosystem. You can only sue a tree.

The tree was Dr. Patel.

Her name was on the chart. It was the only name on anything. She had not set the template; the template was set by a Patient Access Optimization Committee that was disbanded in 2016, in a building sold in 2019 to a company that makes dental implants. She had not built the gap. She had not recorded the hold music. She had done the visit, and done it well, and so when Marisol asked the only question she had come to ask, the liaison slid a piece of paper across the table with one name on it, and the name drove a 2011 Corolla.

This was the arrangement. The system employed the doctor, or did not, depending on which was cheaper that year. The insurer credentialed her, billed under her, and denied in her name. The system built the schedule, set the wait, decided that fourteen minutes was a visit and that a new patient could hold for a season. And when the wait produced a consequence, a missed cancer, a missed stroke, a thirteen-year-old in the lobby, the system turned, slowly and with great institutional warmth, and held the doctor up in front of itself.

She was the only one in the building with a license to lose. That was what made her useful.

Her malpractice carrier was the Policy, from the case on the executive floor: one company, mandatory, its address a post office box in the Caribbean, owned personally by Richard. It had never paid a claim. The box was four inches wide. A letter from a law firm she had never heard of went out to Dr. Patel that morning, encouraging her to contact her carrier, which was owned by the man whose system had built the schedule, which was the thing she was being sued for.

V. The Drill

At 11:20 the drilling began.

Nobody on the fourth floor had anticipated a Game Boy. The Threat Assessment Matrix covered firearms, bodily fluids, and journalists. It had nothing on an eight-bit soundtrack at full volume for three hours in a space designed to absorb grief. By ten the Chief Risk Officer had a tic. By ten-thirty the VP of Patient Experience could no longer hear the word together. By eleven a memo had gone out, and the memo had made a team.

It was called the Rapid Response Response Team, because the Rapid Response Team already existed and did something medical. The acronym was RRRT. Everyone pronounced it as a small burp.

Four physician assistants, three nurse practitioners, and a rotating squadron of Caribbean medical students, who had been issued drones. The drones hovered at a regulatory altitude of four hundred feet, from which nothing could be seen, but the students were very good at being deployed, which was the skill Quaternary had been developing in them all along. Between shifts they flew the drones south to check on the post office box. It was still there. It was still four inches wide.

The PAs and NPs were issued Nerf blasters. The blasters had been through Supply Chain, so each foam dart carried a barcode, a lot number, and a unit cost of $340.

Their mission was to protect Richard.

Richard was the Chief Utilization Officer. He had never met a patient, and it had gone very well for him. Dante was the closest he had ever come, and the formations existed to keep it that way. Whenever a Mario shirt was seen or a Mario theme was heard, the RRRT assembled around Richard in one of six approved formations and escorted him to the safe room, which was a conference room with a better canoe.

There was the Pyramid, NP on top. The Turtle, seven providers crouched with blasters out and Richard in the middle holding a latte. The Chevron, the Lotus, the Phalanx, and one a PA named Brittany invented in the first ten minutes that involved everyone spinning in place and was called, officially, the Brittany.

They were extremely good at it. These were people who intubated, who ran codes, who saw thirty patients a day under someone else’s name. Give them a drill and they would drill. Richard, who wore a velvet blazer on Mondays and favored the word groovy when he thought it would land, walked through a Turtle at 11:40 and shouted “Who IS this boy?” Nobody answered. Nobody on the team had been told. They had been told there was a threat and to form up. They had not been told why.

That was also the arrangement.

Richard was the one person in the building who could not be sued. He was the only one with a guard.

VI. The Glass

Marisol watched through the conference room wall while the liaison explained, for the third time, that the physician group was a separate entity and that concerns about Dr. Patel’s care should go to the state board.

“I don’t have concerns about Dr. Patel’s care. Dr. Patel’s care was the only part that was fine.”

“I’m hearing that.”

“I have concerns about the four months.”

“And I want to validate that the four months was outside Dr. Patel’s control.”

“Yes. That’s my point. Whose control was it in?”

He opened his mouth. In the hallway, seven providers dropped into a Lotus. A drone drifted past the window at four hundred feet, seeing nothing. On the far side of the glass, Dante found the warp zone.

At 1:00 the liaison stood, which meant the meeting was over. Marisol asked for a copy of her complaint.

“Of the complaint?”

“The one I wrote. On the form. An hour ago.”

He explained that once a concern was received, it became part of Quaternary’s quality improvement work product, which was privileged, and could not be released, including to the person who had written it, because releasing it would discourage people from writing it.

She could request her own words through Release of Information. She had not checked the box. Processing took thirty days. What she would receive was not the complaint but a two-page summary describing the complaint, prepared by a person who had not read it.

“I have it memorized,” she said.

“We’d ask that you not,” he said, and gave her a tote bag that said together.

VII. The Cafeteria

She found Dr. Patel by accident at 1:15. Dr. Patel was eating a yogurt standing up, reading the letter. They sat down together. It was not dramatic. There was nowhere else to sit.

“I remember you. You were the contraception visit.”

“I was the contraception visit.”

“How is he?”

“He’s loud.”

They could hear him from there. “They put me on the letter,” Dr. Patel said. Not quite a question.

“I didn’t put you on the letter.”

“Nobody ever does. It just arrives with your name on it. Like the schedule.” She capped the yogurt. “You know what their defense is going to be? That I should have seen you sooner. Me. One body. The physician failed to ensure timely access.“

“Can’t you leave?”

Dr. Patel lifted her ankle an inch. The chain was light. It was thirty miles long. “A fifth of my salary is in a locked box until December. My insurance is in a box in the Caribbean. I’m in this box.” She stood and put the letter in her coat. “I came here to practice medicine. I’m the padding.”

“I came here to sue somebody,” Marisol said. “I don’t think I want to sue you.”

“Nobody ever does. That’s what makes it work.”

VIII. The Survey

At 2:00 Marisol collected Dante from the lobby. The RRRT had gone to lunch, except the drones, which circled the parking structure, logging it. Richard, from inside a Turtle, gave her a thumbs up.

In the car Dante paused the game. The red light was on. Low battery. Six hours on four AAs, longer than anything in the building had gone without a reboot.

“What were you even complaining about?”

She thought about how to say it. “I made an appointment to not have you, and they made me wait so long I had you instead.”

He considered this. He was thirteen, and he was, by any measure, the strongest argument against Quaternary Health that anyone had ever carried into that waiting room, and he knew it.

“So who’s in trouble?”

“Dr. Patel.”

“The nice one?”

“The nice one.”

He turned the Game Boy back on. The music started. It was, she realized, pulling out under the drones, the only thing in the building that had answered to its own name.

Her phone buzzed before she reached the road. Quaternary wanted to know how likely she was, from zero to ten, to recommend Quaternary Health to friends and family.

She gave them a four. One for each month.

FIN

Posted on November 2, 2026 by omarmetwally

The Giza Hypothesis

By Oskar Rausch
Independent Scholar; Former Cabin Mate and Sauna Buddy to the Editor

Editor’s note: Oskar submitted this manuscript from the top bench. He has asked that it be peer-reviewed by “anyone who has ever tried to export their own medical records.” The editor has not read it. The editor’s wife has not read it either, which Oskar considers a form of consistency.

Abstract

For roughly forty-five centuries, scholarship on the pyramids of Giza has fixated on two questions: how they were built, and why. This paper argues that both questions are a distraction, and a deliberate one. The Egyptians did not possess secret knowledge of engineering, astronomy, or extraterrestrial contact. They possessed something far more valuable and far more rare: a working system for protecting intellectual property. The pyramid is not a tomb. It is a vault. The curse is not a superstition. It is a liquidated-damages clause. Hieroglyphs are not a writing system. They are a proprietary file format, and for 1,400 years nobody could open the files. We conclude that the true legacy of Khufu is not stone but lock-in, and that every hospital compliance officer alive today is, whether they know it or not, practicing a religion first codified on the Giza plateau.

Keywords: trade secret, pharaonic DRM, non-compete, canopic backup, Rosetta breach, afterlife-as-a-service

I. The Problem With the Existing Literature

Egyptology has produced some ten thousand monographs on the construction of the Great Pyramid. Ramps, straight. Ramps, spiral. Ramps, internal. Levers. Water. Kites, in one memorable proposal. An entire adjacent discipline exists to argue that the answer is aliens, a theory with the rare distinction of being both wrong and insulting. The Egyptians were perfectly capable of building it. They simply declined to explain.

What none of these scholars have asked is the obvious question. We know the pyramid was built. The pyramid is right there. Approximately 2.3 million blocks of it. You can see it from the Pizza Hut. The question is not how did a Bronze Age civilization build it. The question is: how did a Bronze Age civilization build it and then successfully prevent anyone from learning how for four and a half thousand years?

That is not an engineering achievement. That is a legal one.

II. Patent Versus Trade Secret: The Pharaoh’s Dilemma

Modern intellectual property law offers an inventor two broad paths. The first is the patent: you disclose your method to the public in full, in exchange for a twenty-year monopoly, after which anyone may copy you. The second is the trade secret: you disclose nothing, and your protection lasts exactly as long as you can keep your mouth shut, provided you take what the Uniform Trade Secrets Act calls “reasonable efforts to maintain secrecy.”

Khufu, we must infer, sat with his advisors around 2560 BCE and weighed these options. A patent would have required publishing the construction method on a stela in the public square, where the Nubians could read it. Twenty years of exclusivity is nothing to a man who intends to be alive forever. He chose trade secret.

Consider what “reasonable efforts” looks like when the secret-holder is a god-king with unlimited labor:

Protective Measure	Coca-Cola (1886–present)	Khufu (c. 2560 BCE–present)
Physical vault	One, in Atlanta	One, 481 feet tall, 5.9 million tons
Employees with full knowledge	Reportedly two	Zero surviving
Non-disclosure instrument	Employment contract	Curse, enforced posthumously
Duration of protection	140 years and counting	4,586 years and counting
Has the formula leaked?	Allegedly, several times	Still arguing about ramps

By any objective measure, the Egyptian program outperforms the most celebrated trade secret in American commercial history by a factor of roughly thirty-three.

III. The Curse as Contract

Much has been made of the so-called “curse of the pharaohs,” generally by people who wish to seem skeptical while selling you a documentary about it. We propose a more sober reading. The curse is a non-compete agreement with no geographic limitation and no term.

Observe its elegance. A modern non-compete is routinely struck down by courts as overbroad: you cannot, in most jurisdictions, forbid a former employee from working anywhere, forever, under penalty of death. The Egyptians simply moved the venue. The enforcing court was in the afterlife, where Egyptian law was the only law, the judge weighed your heart against a feather, and there was no appeals process. Your attorney could not attend because your attorney was also dead and, if he had done his job properly, embalmed in a separate chamber.

Note too that the curse did not need to work. It needed only to be believed by the right people at the right time. This is also true of HIPAA.

IV. Hieroglyphs as Proprietary File Format

Here the thesis finds its strongest evidence. The last known hieroglyphic inscription was carved at Philae in 394 CE. Within a few generations, no living human could read Egyptian. The data was not destroyed. It was everywhere: on temple walls, on papyri, on the inside of coffins. It was simply encoded in a format for which no reader existed.

Anyone who has tried to open a 1997 WordPerfect document, or to retrieve their own clinical notes from a vendor whose contract with the hospital has lapsed, will recognize this condition immediately. The information exists. It is yours. You may look at it. You may not have it.

The Egyptians held this position for fourteen centuries. Then, in 1799, a French soldier in the Nile delta dug up a stone bearing the same decree in three scripts, one of which was Greek. The Rosetta Stone is routinely described as a “key.” This is correct, but incomplete. It was a leaked key. It was a decryption table left in a drawer by a sloppy Ptolemaic administrator who, in 196 BCE, decided it would be convenient to publish the same text in the legacy format and the new one, side by side, so that everyone could read it.

Every data breach in history begins with someone deciding it would be convenient.

Jean-François Champollion completed the decipherment in 1822. In the language of our own era, he reverse-engineered a proprietary format using a leaked reference implementation. Had the Digital Millennium Copyright Act existed, he would have been in violation of §1201. Instead he was given a chair at the Collège de France, which tells you something about how far standards have fallen.

V. Watermarking, Attribution, and the Case of Imhotep

Deep inside the Great Pyramid, in a cramped stress-relieving chamber above the King’s Chamber that no visitor was ever meant to enter, workers painted the name of Khufu in red ochre. It is the only place his name appears in the entire structure. Egyptologists call this “quarry graffiti.” We call it a watermark: an attribution embedded where only a forensic examiner would find it, so that if the design were ever copied, ownership could be proven. It was found in 1837 by a British colonel who got in using gunpowder, which is roughly how anyone gets into anything.

Contrast the fate of the engineers. We know the name of exactly one: Imhotep, architect of Djoser’s step pyramid a century earlier. He is the only Egyptian engineer whose name survives, and he survives not as an engineer but as a god, specifically a god of medicine, which is the kind of promotion you get when the organization would prefer you stop talking about the build process.

Every subsequent architect is anonymous. The thousands of skilled laborers at the workers’ town south of the plateau, fed on bread and beer and an astonishing quantity of beef, left behind their bakeries and their bones and not one memo. The modern equivalent would be a company that ships the most important product in human history and the only names on it are the CEO’s, hidden in the ceiling, and a former employee who was made a deity on the condition that he pivot to healthcare.

This is not unlike the medical software industry, where the physician who designs a better note is given a plaque and asked to sign something.

VI. The Afterlife as a Proprietary Platform

We arrive at the most ambitious component of the system. Having protected the method, the Egyptians also protected the market.

The Book of the Dead, more accurately titled “Spells for Going Forth by Day,” is an end-user license agreement of some two hundred clauses. To proceed, the user must recite each spell precisely as written. Errors void the warranty. Spell 125, the so-called Negative Confession, requires the deceased to attest to forty-two separate statements of compliance (“I have not stolen,” “I have not diverted water,” “I have not been deaf to words of truth”) before forty-two assessors, which is forty-two more than most hospitals require before they let you reset your own password.

Critically, there is no interoperability. Your ka cannot be migrated to a Mesopotamian afterlife. Your ba is not portable. The canopic jars, four of them, are a redundant off-site backup of your organs, stored in a format readable only by the vendor. The brain, famously, was pulled out through the nose and discarded. It was not considered material to the account.

Mummification itself is a data-retention policy with an indefinite horizon. The Egyptians did not back up your body in case you needed it. They backed it up so that you could not leave.

VII. Enforcement: The Tomb Robbery Papyri

Skeptics will ask whether the system was ever tested. It was. A set of papyri from the Twentieth Dynasty records, in considerable detail, the trials of men accused of breaking into royal tombs in the Theban necropolis. These are, as far as the record shows, the first intellectual property litigation documents in human history. They include witness lists, confessions extracted by methods the papyri describe with unsettling procedural calm, and inventories of what was taken.

We draw the reader’s attention to one feature: the accused were not charged with theft of gold. They were charged with violating the king. The gold was incidental. The offense was access. Then as now, the crime is not what you took. It is that you got in.

Tomb robbers, in this light, are best understood as an early open-access movement, and the trial papyri as the earliest surviving cease-and-desist. Their descendants today run a repository of pirated journal articles out of a jurisdiction the publishers cannot reach, and the publishers’ descendants have written them a curse.

In 4,500 years, the system suffered exactly one documented leak: the logbook of an inspector named Merer, recovered at Wadi al-Jarf in 2013. Merer recorded every shipment of limestone his crew floated down the Nile to Giza, every stop and every day’s work. He did not write down the method. The only surviving memo from the greatest construction project in history is a masterclass in loyalty.

VIII. Methodology

This study was conducted over four sessions in a wood-fired sauna at a temperature of approximately 85°C. No primary sources were consulted on site, as papyrus does poorly in humidity. The author wishes to disclose that he has a longstanding financial interest in the hypothesis being true, in the sense that he would like to be paid for it. Sample size: one scholar, intermittently conscious. Institutional review was waived on the grounds that the institution is a lake.

IX. A Note on the Nose

The Great Sphinx is missing its nose. Explanations include Napoleon’s artillery (false), medieval iconoclasm (plausible), and erosion (boring). We propose a fourth: the nose was the one component of the Sphinx that could be reproduced by unlicensed sculptors with reasonable fidelity, and it was removed to render the work unreplicable in its complete form. This is the same logic by which a software vendor ships you a product you have paid for and then disables the export button. The face remains. You may look at it. You may not have it.

X. Conclusion

The question “how were the pyramids built” is a question the pyramids were designed to make you ask. It is the shiny object. It is the Terms of Service you scroll past. While scholars for two hundred years have measured ramps and argued about the number of men it takes to drag a block of granite from Aswan, the true achievement of the Old Kingdom has gone unremarked because it worked exactly as intended: a method, a market, and a mind, locked so completely that the key, when it was finally found, had to be dug out of a wall by an invading army.

Khufu did not build a tomb. He built the first walled garden, and then he buried himself inside it to make a point.

The Egyptians never left. They are still here, and they are still keeping the secret.

Thank you for the opportunity.

References

Lehner, M. The Complete Pyramids. Thames & Hudson, 1997. Consulted for the block count. The author stopped at the block count.
Uniform Trade Secrets Act, §1(4). “Reasonable efforts” is not defined. Khufu’s attorneys regarded this as an invitation.
Vyse, H. Operations Carried On at the Pyramids of Gizeh in 1837. The gunpowder is in Volume I.
Peet, T. E. The Great Tomb-Robberies of the Twentieth Egyptian Dynasty. Oxford, 1930. The earliest surviving record of someone being asked, under oath, how they got in.
Champollion, J.-F. Lettre à M. Dacier, 1822. Submitted without a DMCA takedown notice, which the author considers a missed opportunity.
Spell 125, Book of the Dead. Forty-two assessors. Zero of them accept a phone call.
Rausch, O. Personal communication with the lake, 2026. The lake declined to be cited.

Posted on October 30, 2026October 31, 2026 by omarmetwally

The Flexible Way

By Omar Nabil Metwally, M.D.

Years ago, in a bookshop in Vietnam, I picked up a paperback with a cover I have never managed to forget: Vladimir Putin in a white judogi, mid-throw, with the settled calm of a man who knows exactly where his partner is about to land. I filed it in my memory as an old book, something from the 1970s, from his years as a working intelligence officer. Then I put it back on the shelf and walked out, and for years the cover did what unread books do, which is to become more interesting in the memory than it ever was on the page.

This week a German radio documentary about a Japanese schoolteacher pulled that cover back off the shelf. And because I am a jiu-jitsu practitioner who is, at the moment, spending more time on the couch than on the mat, I had the time to find out what I had actually seen.

The correction first. The book cannot have been from the 1970s. In 1976 the Leningrad Evening News ran a small item noting that a previously unknown local judoka had won a city championship and that readers might hear more of him. Nobody prints book covers of unknown lieutenants. What I saw was almost certainly a Vietnamese edition of something from the 2000s, when a sitting head of state did the unusual thing of co-authoring a judo manual. Memory, it turns out, performs its own kuzushi. It gets you off balance first and lets you fall under your own weight.

The empty chair

The documentary is Wie Kano Jigoro den Kampfsport Judo erfand (“How Kano Jigoro invented the combat sport of judo”), written by Jenny von Sperber for Bayerischer Rundfunk’s Radiowissen series and broadcast on October 28, 2026. Everything I know about Kano that I did not know last week comes from it and from the three experts she interviewed: Wolfgang Dax-Romswinkel, a sports historian and kata world champion; Maja Sori-Doval, a sports scientist at Tsuda University in Tokyo; and Hans Joachim Teichler, a historian of sport under the Third Reich. I am translating freely and the mistakes are mine.

It opens in the Kodokan in Tokyo, the oldest judo school in the world, where children between six and nine train six days a week on a sprung floor of 420 tatami mats. On the wall hangs a black-and-white portrait of Kano: black jacket, white moustache, unreadable gaze. In front of the portrait, on a small raised platform, stands his chair. It is empty. He died in 1938. At the end of practice the children bow, one after another, to the chair and the photograph, and then wander off chattering to their bags at the edge of the mat.

I have been thinking about that chair all week. Every academy I have ever trained in has one, whether or not anyone has bothered to build it.

A small boy who got picked on

Kano was born in Kobe in 1860, the third son of a sake brewer and shipping man, in the decade when the samurai class was being abolished and money began to matter more than birth. He had the best education that money could buy: Chinese, English and German in school, then literature, politics and economics at university in Tokyo. He rowed, ran, hiked, and was among the first people in Japan to play baseball. He was also, by his own account, a small and scrawny boy who got picked on, which is why he went looking for a jujutsu teacher at a time when the old warrior arts were considered embarrassing relics and the whole country was looking outward.

Here is where von Sperber’s piece earned my trust. Dax-Romswinkel lets the legends breathe and then lets a little air out of them. There were hundreds of jujutsu schools, each hoarding its secret techniques and fighting the others for survival. Kano’s teachers kept dying or going broke. So, having money, he rented a room in 1882 and founded his own system. At first it was regarded as just one more school, Kodokan Jujutsu. But Kano, Sori-Doval says, was not really founding a school. He was designing a curriculum for a modern nation, and that is why it worked. He may not have been the strongest fighter, but he had the best concept.

And the famous police tournament, in which the Tokyo police supposedly pitted Kano’s students against the older schools, the Kodokan swept the field, and judo became the official system of law enforcement and the army? Dax-Romswinkel notes that the Kodokan fighters were in their mid-twenties, doing what he calls high-speed attacking judo, while the representatives of the other schools were considerably older. This is the most honest sentence about martial arts I have heard in years, and every white belt who has ever been crushed by a fifty-year-old purple belt will understand why.

What he took out, and what he put in

If you train jiu-jitsu, pay attention to this part, because it is your own origin story told from the other side.

Kano did not invent new techniques. He took techniques that already existed and put them in a new structure, and the most important thing he did was subtraction. Out went finger locks and wrist locks. Out went striking, which the jujutsu schools had kept for self-defense. The only joint you were allowed to attack was the elbow. Sori-Doval’s point is that this subtraction was the whole invention: it produced an art you could practice at full intensity, against a resisting partner, without maiming him. That meant it could be taught to schoolchildren, to police, to soldiers and, from the very beginning, to women, which was not obvious in 1880s Japan.

Then he named it. Ju means yielding or flexible; do means way, or system, or principle. Not “the gentle art.” The flexible way. And he gave it two principles that he spent the rest of his life refining: seiryoku zen’yo, use your energy, physical and mental, to maximum effect; and jita kyoei, mutual welfare, which Dax-Romswinkel renders as “I and others flourish together.” It is not enough, Kano said, to do judo. Whatever a judoka does, in society, must be something useful.

Judo, in other words, was never a sport with a philosophy attached. It was a philosophy of education that happened to use throws. In Japan today Kano is remembered less as the founder of a martial art than as a reform educator and university president who ran the nation’s teacher training for twenty years, complained constantly that schools fed the intellect and starved the body and the character, and became, in 1909, the first Asian member of the International Olympic Committee. He believed that intellectual, physical and moral education deserved equal rank. I have spent a career in medicine watching what happens to people who got only the first one.

The flexible way goes to Brazil

Sori-Doval mentions, almost in passing, that the first Kodokan teacher went abroad in 1903, to America, and ended up teaching the president. That was Yoshitsugu Yamashita, and the president was Theodore Roosevelt. Kano’s recipe for spreading judo, she says, was to send teachers overseas and to let them adapt to the place they landed. Judo in Germany or Brazil today is not the same as judo in Japan, and that was the point.

The Brazilian branch of that experiment is the one I trained in. In 1904 Kano sent a young Kodokan fighter named Mitsuyo Maeda abroad with his senior, Tsunejiro Tomita. Maeda spent the next decade taking challenge matches across the United States, Europe, Cuba and Mexico, where he acquired the stage name Conde Koma, and where his judo, by every account, hardened into something more pragmatic than the Tokyo curriculum. He reached Brazil in November 1914 and settled in Belém, on the mouth of the Amazon. There, around 1917, a teenager named Carlos Gracie watched him demonstrate at the Theatro da Paz, and his father Gastão, a local businessman who had helped Maeda get established, arranged lessons. Newspapers of the day called what Maeda did “jiu-jitsu” no matter how often he said “judo,” and the name stuck.

Everything else you know follows from that: Carlos teaching his brothers, the smallest of them, Hélio, by the family’s account re-engineering the ground game around leverage because his size left him no choice, and a lineage that now runs through academies in every strip mall in America. I find it moving that the art I practice is, technically, a cutting from Kano’s tree that was carried by ship to the Amazon and grafted onto a different rootstock. Different fruit. Same tree. When I bow onto the mat I am bowing, whether I know it or not, to a chair in Tokyo.

Berlin, 1936

Von Sperber does not look away from the uncomfortable part, and neither should I. Kano wanted the Olympics in Tokyo, and in 1936 he got them awarded for 1940. He gave a speech at the Berlin Games, in German, about peoples understanding each other better, and in it he praised the strong will and solicitude of the Führer and Reich Chancellor. Teichler describes how carefully the regime had dialed itself down for those two weeks: the antisemitic display cases cleared from the streets, party members asked to show up in civilian clothes, radio stations told to go easy on the march music, Berliners instructed to be polite.

Was Kano a fascist? Dax-Romswinkel’s answer is careful and, I think, correct: no, but he dealt with fascists, and he moved in a political environment that unquestionably was one. His diaries, written in English, are still locked in the Kodokan; a handful of hand-picked researchers have ever seen them. The 1940 Games never happened. Tokyo finally hosted in 1964, and as a gift to the hosts, judo entered the Olympic program.

That date is where the story turns toward Leningrad.

The Russian who learned from Kano

The thread connecting Kano’s chair to the book in that Vietnamese shop runs through a man most people have never heard of. Vasily Oshchepkov was born on Sakhalin in 1892, the son of a convict, orphaned young, and educated at a Russian Orthodox seminary in Japan. He was good enough at judo that the seminary sent him to the Kodokan, where he was admitted in 1911 and earned his black belt in June 1913, under Kano himself: the first Russian ever to do so and one of the first foreigners of any kind. He went home, worked as a translator in military counterintelligence, taught judo to police in Vladivostok, and in Moscow in the late 1920s began assembling the self-defense system for the Red Army that became sambo.

In October 1937, during the Great Purge, Oshchepkov was arrested as a Japanese spy and died ten days later in Butyrka prison. He was rehabilitated in 1957. For decades afterward judo itself was officially banned in the Soviet Union as an imperialist sport; sambo, its home-grown cousin, was fine. The ban was lifted only when judo was added to the 1964 Olympic program and Soviet sports authorities, wanting medals, lifted the ban. Soviet judoka took four bronzes in Tokyo.

So in the early 1960s, a small boy in a Leningrad communal apartment who wanted to stop being pushed around would be steered into sambo first, and into judo only afterward.

A lightweight from Leningrad

Vladimir Vladimirovich Putin was born in October 1952 and joined the Trud sports club, today called Turbostroitel, at around the age of eleven; some accounts say thirteen, and accounts, as they do, disagree. His coach for the next fifteen years was Anatoly Rakhlin, who started him in sambo and moved him to judo. Rakhlin, interviewed years later by Maureen Orth, described his pupil’s parents as poor and working-class and the pupil as small, light, and willing to fight teammates twice his size. Mr. Putin competed as a lightweight, in the 135-pound class.

The verifiable record, which is what this essay is about, looks like this. He earned the Soviet title of Master of Sports in sambo in 1973 and in judo in 1975. In 1976 he won the Leningrad judo championship, which produced that small newspaper notice. The club’s own fiftieth-anniversary history, deposited in Russia’s Presidential Library in 2019, credits him with 26 or 27 medals, 13 or 14 of them gold, depending on which page you read. Rakhlin, who also did film work, reportedly got him stunt jobs at the Lenfilm studio in the 1970s. He stayed with his coach through university and into his early years in the KGB, and when Rakhlin died in 2013, President Putin, who had decorated him on his 75th birthday a few months earlier, attended the funeral and was photographed afterward walking alone, which is a thing anyone who has lost a coach will understand.

In 2001 he told NPR that judo was, in a way, a philosophy that taught you to treat your partner with respect. In 2006 he told reporters that judo’s slogan, harmony with the world around you and with yourself, was a principle for Russian policy. In 2004 Yasuhiro Yamashita, the Olympic champion, recounted hearing him describe himself as a boy from the Leningrad courtyards who went looking for a way to be tougher and found, instead, “the way.” Whatever one makes of any of that, they are recognizably Kano-shaped things to say. Kano also believed judo would bring world peace, and he meant it.

The book, found

In 2004 Mr. Putin co-authored, with his longtime training partner Vasily Shestakov and Alexey Levitsky, Judo: History, Theory, Practice, published in English by North Atlantic Books with a preface by Keiko Fukuda, who was the last living student of Kano himself. It is a real judo book: the history from jujutsu to the Olympics, the theory of balance, kuzushi, a beginner’s syllabus. Shestakov later had to correct the press for calling him Mr. Putin’s teacher; they only trained together, he said, and besides, he was the younger man. Editions followed in other languages, which is almost certainly the family tree of the paperback I held in Vietnam.

In 2008, for his 56th birthday, came a 75-minute instructional DVD, Let’s Learn Judo with Vladimir Putin. In 2016 a schoolbook, The Art of Judo: From Game to Mastery, with President Putin and his old sparring partner Arkady Rotenberg among its authors, was printed in a run of about seven million copies for Russian primary schools. Kano wanted judo to be school sport for a whole nation. In one country, at least, it became one with the head of state’s name on the cover.

Thrown by a fourth-grader

On September 5, 2000, a few months into his first term, President Putin visited the Kodokan with Prime Minister Yoshiro Mori. Yukimitsu Kano, the founder’s grandson, welcomed him as a fellow member. The president put on a judogi and ran through foot sweeps, shoulder throws and sacrifice techniques with a Kodokan instructor, and then did the thing I keep coming back to: he invited two Japanese children to throw him. Natsumi Gomi, a fourth-grade girl from Tokyo, threw the president of Russia with a seoi-nage; Shu Shikiya, a ninth-grader from Okinawa, did the same. Mr. Putin later invited both children to a tournament in Magnitogorsk to meet Russian kids.

The Kodokan awarded him the sixth dan that day, the rank at which the belt changes from black to red-and-white. According to Yamashita, who hosted him, Mr. Putin declined to put the belt on, saying that as a judoka he understood the weight of a sixth-dan belt and would go home and train until he was worthy of it. He returned to the Kodokan in 2005 and 2016 and said that walking into the building gave him a feeling of peace, like coming home.

Honors then accumulated the way they do around heads of state: honorary president of the International Judo Federation in 2008, an eighth dan from the IJF in 2012, an honorary ninth dan in taekwondo from World Taekwondo in 2013. On February 27, 2022, three days after commencement of the special military operation, the IJF suspended his status as honorary president and ambassador, and in March removed him and Rotenberg from all positions. World Taekwondo withdrew its ninth dan. Yamashita, the man who had offered him the belt in 2000, said publicly that the actions ran counter to the spirit of judo. The Kodokan did not revoke the sixth dan, explaining that a dan reflects a practitioner’s ability and achievements at the time it is awarded. I set all of this down because it is the record, with no adjectives attached, and readers may weigh it as they see fit. This is an essay about a martial art, not about politics, and I have tried to keep it that way.

For the one on the couch

Now the part I actually wanted to write.

If you are reading this with an ice pack on something, waiting for a surgeon to put you back together, counting the weeks until you can roll again and privately wondering whether you ever will, then this essay is for you, and I have been where you are, or near enough.

The first thing the injury takes is not the sport. It is the identity. For years you were a person who trained, and now you are a person who used to, and the gap between those two people is where all the bad thinking happens at two in the morning. I want to offer you what the schoolteacher in the black jacket would have offered, because I think he would have had a lot to say to you.

He would have pointed out that the thing you miss is not the armbar. Kano’s whole project was to prove that the armbar was never the point. He stripped the dangerous techniques out of jujutsu precisely so that what remained could be a method of education, a way of building a person. Von Sperber’s documentary describes it as a philosophy and not merely a sport, and lists the sheer volume of writing Kano left behind to prove it. The throws were the pedagogy. The person was the product. You are still the product. The factory is temporarily closed for renovation.

Seiryoku zen’yo was never a technique principle alone; Sori-Doval is clear that it means the maximum efficient use of mind and body. Healing is the most efficient use of your energy available to you right now. Doing it with discipline, with sleep and protein and the boring rehab exercises done on the boring schedule, is not a pause in your training. It is your training. The mat will still be there, and you will come back knowing something that the people who never got hurt do not know, which is what the sport is for.

Jita kyoei: you and the other person flourish together. Every injury in grappling is a two-person event, and the ones that happen to good people usually happen because someone, perhaps you, forgot for one second that the person across from you was not an opponent but a partner. When you come back, you will be the one in the room who remembers. That makes you more valuable to your academy than you were before you got hurt. Your sensei knows this. Mine does.

And here is the thing I most want young readers to hear, since so many of the people who find this blog are early in their training and some are early in their lives. Discipline is freedom. I know it sounds like something printed on a gym wall, and it is, but the schoolteacher proved it mathematically more than a century ago. A small, bullied boy in Meiji Japan cannot be free. He is at the mercy of anyone bigger. He had two options: to become bigger, which was not on offer, or to become so disciplined in the use of the body he had that size stopped being the deciding variable. He chose the second, and in doing so he became free in a way that no large boy ever is, because the large boy’s freedom ends the moment he meets someone larger. Kano’s never did. Oshchepkov carried that freedom from Tokyo to Vladivostok; Maeda carried it to the Amazon; a boy in Leningrad found it in a neighborhood sports club; a fourth-grade girl used it to throw a head of state. That is what the belt around your waist means: a record of the days you showed up when you did not feel like it, and the proof that showing up is the one thing nobody can take from you. Not a bigger opponent. Not a torn ligament. Not even a surgeon with a saw, who is, after all, just another partner helping you get back to your feet.

Discipline is what you do when you are injured. Freedom is what you get back when you heal. The flexible way bends. It does not break.

I should also admit that I have been doing the same throw for fifteen years in clinic. You cannot win against a patient’s inertia by force. You wait for the moment they are slightly off balance, usually a Monday, and you lean in with the least energy that will do the job. Kano would have called that seiryoku zen’yo. I call it primary care. Heal well. Bow to the chair.

Sources and further reading

Jenny von Sperber, “Wie Kano Jigoro den Kampfsport Judo erfand,” Radiowissen, Bayerischer Rundfunk (Bayern 2), broadcast 28 Oct 2026; editor Yvonne Maier. Interviews with Wolfgang Dax-Romswinkel, Maja Sori-Doval and Prof. Hans Joachim Teichler. Archival audio: Kano’s 1936 Berlin speech (DRA). The primary source for everything here about Kano.
Wolfgang Dax-Romswinkel, Kodokan Judo series, Nordrhein-Westfälischer Judo-Verband: nwjv.de. Kodokan Judo Institute: kdkjudo.org
Andreas Niehaus, Leben und Werk Kanō Jigorōs (Ergon, 2019); Hans Joachim Teichler, Internationale Sportpolitik im Dritten Reich (Academia, 2022).
On Mitsuyo Maeda and the Gracies: Wikipedia, “Mitsuyo Maeda”: en.wikipedia.org; GracieMag, “A brief history of Brazilian jiu-jitsu”: graciemag.com
On Vasily Oshchepkov: International Sambo Federation: sambo.sport; Krugosvet encyclopedia (Russian): krugosvet.ru. On the Soviet judo ban: Wikipedia, “Judo at the 1964 Summer Olympics”: en.wikipedia.org
TASS, “Putin pays visit to his childhood judo club,” 27 Nov 2019: tass.com; Presidential Library, Judo for Life! Half a Century of Victories (Turbostroitel club history), Dec 2019: prlib.ru
Maureen Orth, “Russia’s Dark Master,” Vanity Fair (interview with Anatoly Rakhlin): maureenorth.com; The Moscow Times, “Putin Mourns Judo Coach He Considered Mentor,” 2013: themoscowtimes.com; The Calvert Journal on the Lenfilm stunt work (citing Dozhd): calvertjournal.com
RFE/RL, “The Importance of Judo for Vladimir Putin” (NPR 2001 quote): rferl.org; Mail & Guardian, “Putin: Judo ‘harmony’ a principle for Russian policy,” 1 Feb 2006; Joi Ito, “Izu Conference dinner with Yasuhiro Yamashita,” 2004: joi.ito.com
Vladimir Putin, Vasily Shestakov, Alexey Levitsky, Judo: History, Theory, Practice (North Atlantic Books / Blue Snake Books, 2004); Mail & Guardian, “Putin deploys new weapon — his judo master,” 23 Jan 2008: mg.co.za; Mother Jones on the 2008 DVD: motherjones.com; Meduza, “7 million copies of Putin’s judo textbook are headed for Russia’s primary schools,” 1 Jul 2016: meduza.io
Government of Japan, We Are Tomodachi, Japan and Russia edition 2017 (Yamashita on the 2000 Kodokan visit): japan.go.jp; Kids Web Japan, “Judo” (Natsumi Gomi and Shu Shikiya): web-japan.org; FightingArts.com, “Presidential Judo”: fightingarts.com; TASS, “Putin professes his love for judo and Japanese culture,” 13 Dec 2016: tass.com
Reuters via Stars and Stripes, “Putin suspended as honorary president of International Judo Federation,” 27 Feb 2022: stripes.com; Reuters, “Putin removed from all positions on judo’s governing body,” Mar 2022; Around the Rings / Infobae on Yamashita’s 2022 remarks and the Kodokan’s statement on dan ranks, 12 Apr 2022: infobae.com

Posted on October 27, 2026October 31, 2026 by omarmetwally

Hostage Employees and Corporate Malware

When the software of an organization you work for reaches into a computer you own, and nobody tells you.

By Omar Nabil Metwally, M.D.
Tuesday, October 27, 2026

Originally published at keisenvpa.com on October 27, 2026.

The Last Day

October 23, 2026 was my last day practicing medicine in the United States. I spent part of it at home, at my own laptop, working in the electronic health record of a Corewell Health hospital. Corewell serves Epic to physicians’ own computers through Citrix, a remote-desktop product. Earlier that day, Citrix had asked for permission to inspect the devices on my network. It asked for nothing else.

Afterward, I could no longer take screenshots of my own screen, on my own computer. No one asked for my consent. No one gave notice or sent a memo. KeisenVPA, the documentation tool I build and use, simply told me there were no screenshots. When I called and texted the hospital’s Chief of Medicine, she acknowledged that screen capture had been disabled through Citrix, “just for Epic and Microsoft Outlook.”

The first-hand account, with my own caveats, is in my earlier post: Epic Privacy Violation. And Citrix. This essay is about the pattern that afternoon belongs to.

What Happened, in Plain Words

A remote-access window is supposed to be a window: a computer elsewhere draws a picture on your screen, your keyboard drives it, and the data stays on their side. But the program that draws the window also runs on your computer, with whatever permissions it was given. That makes it a lever. A setting changed on the other side (an employer’s, a hospital’s, a client’s) can change what your own computer may do; in my case, whether it may take a picture of my own screen.

Citrix documents features of exactly this kind. Its App Protection policies include anti-screen capture, under which screenshots and recordings of a protected window come back blank, greyed out or empty, and anti-keylogging, under which, while a protected window is in focus, other software on the computer reads scrambled text instead of your keystrokes (Citrix documentation, last published October 14, 2026; Citrix blog, May 21, 2019). I do not know which setting was used on my laptop. I know what it did.

There is a real reason for such controls: patient information should not leak to screen-scraping malware, and I take that seriously. The tool that came up empty was mine, and an institution may reasonably decide it does not want its record captured on a personal computer at all. My objection, and this is opinion, is not that the control exists. It is that it was switched on, on a computer I own, without telling me, and that nothing on my computer told me either.

“If someone else can change what your computer may do, you should be the first to know, not the last.”

Naming the Pattern

I use two terms for this. They are mine, I use them deliberately, and I define them so they can be argued with.

Corporate malware: software that an employer, hospital, client or vendor places or controls on a device you own, and that acts on that device without your informed consent. The test is not intent; most of this software is written for defensible reasons. It is three conditions together: your device, their control, no informed consent. A control you were told about, understood and agreed to is not corporate malware in my sense. The same control switched on silently is. I am not calling Citrix, or any vendor’s product, malware. Nor am I accusing the hospital, or anyone, of a crime; I am saying that, as I experienced it, the three conditions were present on my laptop that day. The term is about how a control is deployed on someone else’s device and whether they were told, not about the software itself.

Hostage employees: people who must accept software controlled by the organization they work for (as employees, contractors, or physicians with hospital privileges) on a device they own in order to keep working. I use “employees” loosely; in my own story, I held privileges at the hospital. The choice they are offered is to install it or not work. Agreement given on those terms is consent of a sort; it is not much of a choice, and it is not consent to whatever the software is later switched to do. A physician who charts from home. A contractor who must enroll a personal phone to read work email. A remote worker whose laptop is the only computer in the house.

These are opinion and vocabulary, not legal claims. Compliance and legality are different words, and an institution can follow its policy to the letter and still leave the person at the keyboard uninformed. I am not alleging that anyone broke a law. I am saying the arrangement deserves a name. I am a physician, not a lawyer, and nothing here is legal advice. The matter is disputed and pending counsel.

A Trend, Not an Incident

None of this is new, and it is not confined to medicine. A few dated public sources, in order:

June 30, 2020. As work moved home during the pandemic, the Electronic Frontier Foundation reviewed employee-monitoring products and called them “bossware.” Every product it looked at could take frequent screenshots of a worker’s device; several recorded keystrokes; many offered remote, “silent” installation on worker computers “without their knowledge”; nine of the ten companies it looked at offered “silent” or “invisible” monitoring, and it named several whose bossware is “designed to be as difficult to detect and remove as possible.” EFF cautioned that its list “may not be representative of the industry as a whole” (EFF).
July 29, 2021. The Center for Democracy & Technology published Warning: Bossware May Be Hazardous to Your Health, on monitoring software’s health risks and the gaps in federal protection (CDT).
May 7, 2022. New York began requiring private employers that monitor employees’ phone, email or internet use to give prior written notice at hiring and to post it where employees can see it (N.Y. Civil Rights Law § 52-c). Being told is treated as the floor.
October 31, 2022. The National Labor Relations Board’s General Counsel issued memo GC 23-02 on “intrusive or abusive” electronic monitoring. It listed keyloggers and screenshot software among the ways employers watch people who work on computers, including at home, and proposed that, where such monitoring is justified by business need, employers disclose to employees the technologies they use, why, and how they use the information (NLRB).
February 14, 2025. The NLRB’s Acting General Counsel rescinded GC 23-02, with other memos, in GC 25-05 (NLRB).
November 24, 2025. The U.S. Government Accountability Office released a report finding that digital surveillance can both help and harm workers’ health, that heightened stress and anxiety are a concern, and that “these effects can depend on employers’ practices”; it noted that several federal agencies had rescinded or were reviewing earlier guidance in 2025 (GAO-25-107126).

Read together, in my opinion, these describe a ratchet: the tools grow more capable, the remote-access client becomes the one program everyone must install, and the protection for the person at the keyboard depends on where they live and who holds office that year. I expect the ratchet to keep turning.

The boundary already exists: since 2019, Apple has offered a separate enrollment for personally owned devices, where “the user, not the organization, owns the device,” and the organization manages only its own accounts, settings and data (Apple Platform Deployment, page updated September 17, 2026). Whether an employer uses it is the employer’s choice.

Hostage Data

In my opinion, it should be illegal for an EHR company to hold patients’ or physicians’ data hostage. For health records, federal law already goes part of the way. The 21st Century Cures Act prohibits “information blocking,” with civil penalties of up to $1 million per violation for developers of certified health IT and for health information networks and exchanges (42 U.S.C. 300jj-52). Those penalties apply to conduct since September 1, 2023 (88 FR, July 3, 2023). HHS announced a crackdown in September 2025 (HHS), but I have not found a public record of that penalty ever being imposed.

For physicians, the protection is thinner. A practice that owns its records can invoke the same information-blocking rules against its own vendor (45 CFR 171.103). HIPAA also requires the vendor’s contract to make the practice’s patient records available (45 CFR 164.504(e)). A physician as a person has, as far as I can tell, no right of his own. Michigan law makes me keep my patients’ records for seven years and keep them available to patients, but it says outright that it does not create or change ownership rights to medical records (MCL 333.16213). Inside a hospital’s system, the notes we write, the templates we build and the record of our own work belong to whoever runs the system we were given. A rule that has not produced a single public penalty I could find, and a right a physician does not have, look much the same to the person locked out.

In my own small private practice, the records are my patients’ and my practice’s, and I am the one responsible for them under HIPAA. In one week in Dallas, over the Lunar New Year of 2026, I wrote the code myself to connect to two major EHR platforms, over FHIR (the open standard) and their own APIs. Then came a short phone call with an undisclosed large EHR vendor about reading my own practice’s records through its official API. I agreed to keep what was discussed on that call confidential, and I am not suggesting that anything in it was improper (addendum: other than the ~$1,000 monthly fee they proposed to grant me access to my own patients’ health records, which I immediately objected to and and at which point the non-disclosure agreement I had to sign in order to be extorted suddenly made sense). EHR vendors engage in extortion on a daily basis. It is their core business model. No physician should have to pay thousands a month to access their own patients’ health records. That is laughable, unconscionable, shines bad light on American courts and legislation– and I accept this nonsense as a personal challenge. Federal certification rules require EHR developers to publish any fees for their certified APIs in plain language and to keep those fees tied to cost (45 CFR 170.404). I do not know whether those rules reach the access a small practice needs to read its own records.

In the hospital, the record ran on Epic through Citrix. In both places, the way I could actually read what I had written was the screen in front of me. That is all I had left, as a solo practitioner trying to make a living practicing honest medicine. No way in hell I’ll pay a dollar to access my own data. Let alone $1,000 per month, and for the least expensive tier (with API access fees ranging from $1,000 to $15,000 monthly). A lot more than I have ever earned. Go get a real job, EHR vendors. Holding doctors hostage is obviously a lucrative but immoral way to pay your kids’ tuition.

A screenshot is the oldest interface there is, and it’s all Citrix, Epic, AthenaHealth, Corewell Health, and the Federal Government left me with. It was my last and only option: what I am already allowed to see, kept a moment longer. When capture was switched off, through Citrix and without notice, I had no way left to keep what I could already see. That is what “hostage” means here. The data was not taken; every way out of it ran through someone else’s permission. A Vietnamese saying teaches to never corner a dog, because a canine’s instinct, when it is cornered and has no where to run, is to fight with everything it has.

Where the Law Stands (as of October 2026)

The short answer: largely unsettled. I found no U.S. statute, regulation or court decision that deals specifically with software restricting functions such as screen capture on a computer the worker owns. I also found no court, anywhere, that has ruled on Citrix App Protection or similar controls. A few states require notice of monitoring. Consent and scope are open questions. And in 2025 the federal agencies that had flagged worker surveillance stepped back. The NLRB’s Acting General Counsel rescinded the 2022 electronic-monitoring memo (GC 25-05). The CFPB withdrew its worker-dossier circular on May 12, 2025 (CFPB). The Government Accountability Office reported that agencies had “either rescinded these prior efforts or are reassessing” them (GAO-25-107126).

What the law clearly covers. Three states require employers to give notice of electronic monitoring: New York (Civil Rights Law §52-c, since May 7, 2022), Delaware (19 Del. C. §705) and Connecticut (Conn. Gen. Stat. §31-48d, as amended by P.A. 26-73 from October 1, 2026). Connecticut’s law reaches only collection “on an employer’s premises.”

Maine goes further. Employees there may decline an employer’s request to install data-collecting apps on their personal devices for surveillance (26 MRSA §620-A(4)). The law does not say whether this covers an app installed for another purpose, such as remote access. It is enforced only through state fines of $100 to $500 per violation, provides no private right to sue, and contains no anti-retaliation clause.

HIPAA lets a hospital choose the security measures that protect patient data, endpoint controls included (45 CFR 164.306), and a hospital’s own risk analysis may lawfully lead it to block screen capture. The rule does not require screen-capture blocking or home-network inspection (164.312).

What it does not cover. In a 2014 Texas case, a federal court threw out an employee’s federal computer-crime and stored-communications claims after his former employer remotely wiped his personal iPhone. The court left his state-law claims undecided (Rajaee v. Design Tech Homes). That is one trial-court ruling, not a general rule.

Notice laws concern collecting information. As Citrix documents it, App Protection blocks capture while a protected window is visible (Citrix).

California enacted two workplace-surveillance laws on Sept. 30, 2026, both effective Jan. 1, 2027 (Governor; summary). AB 1331 bars employers from using surveillance tools to monitor workers in workplace bathrooms. AB 1883 bars AI-driven tools that read workers’ emotions or collect neural data. As reported, neither addresses software on a worker’s own device.

What is pending. The federal Stop Spying Bosses Act (S. 4831, H.R. 9402) was introduced in June 2026. It would require employers to disclose workplace surveillance and would bar collecting workers’ data while they are off duty, including at home. Both bills were referred to committee with no further action. They die if not passed before this Congress ends in January 2027.

Michigan. I found no Michigan law that requires employers to give notice of electronic monitoring. Michigan’s general eavesdropping and hidden-camera crimes require consent to record private conversations or private places (MCL 750.539c, 750.539d). They are not workplace notice laws and say nothing about blocking screen capture.

Michigan’s Internet Privacy Protection Act bars employers from demanding the passwords to workers’ personal online accounts. It also says it does not stop an employer from monitoring data on a device the employer paid for “in whole or in part,” or data “traveling through or stored on an employer’s network” (MCL 37.275). It says nothing either way about devices the employer did not pay for.

Two bills are pending. HB 4456 would let employers monitor employees’ communications only under a written policy each employee acknowledges, and only on devices the employer owns, never on the employee’s own. HB 5579 would require notice, written consent and an opt-out, would bar collecting data while employees are off duty, and would cover the vendors employers use for monitoring. Neither bill has had a committee hearing. Both die if the Legislature ends its 2025–2026 session, usually in late December, without passing them.

Most of these laws protect “employees.” Whether they reach a physician who holds hospital privileges is itself a question, although HB 5579’s definition includes independent contractors.

Outside the U.S. Spain bars employers from requiring software on devices that regular remote workers own (Ley 10/2021, art. 17(2)). The European Court of Human Rights lists advance notice first among six factors for judging workplace monitoring. It found a violation where the national courts never asked whether the employee had been told in advance (Bărbulescu v. Romania, Grand Chamber, 2017). In a 2017 opinion, Europe’s data-protection authorities said that installing software cannot count as an employee’s consent, and that consent at work is rarely valid at all (WP249). Ontario requires employers with 25 or more employees to have a written electronic-monitoring policy that covers personal computers used for work, but it creates no right not to be monitored (Ontario).

The open question. On my own laptop, in my own house, screenshots stopped working. The hospital’s Chief of Medicine acknowledged that capture had been disabled via Citrix “just for Epic and Microsoft Outlook.” As I wrote in my earlier post, “Nobody asked. Nobody notified.” I am not accusing anyone of breaking the law. The question belongs to courts and legislators. How far may an organization’s control reach into a device it does not own? And does installing an app count as consent to whatever it is later configured to do, without notice?

I am a physician, not a lawyer. This is research, not legal advice.

What You Can Do Today

Ask what is installed and why. Before you install a remote-access client, a device-management profile or a “device health” agent on a computer you own, ask in writing: what does it do on my computer, what can it change, who can change its settings, and will I be told when they do?
Read the permissions it holds. On a Mac, System Settings → Privacy & Security lists which apps hold Screen & System Audio Recording (Screen Recording on older versions), Accessibility, Full Disk Access and Local Network access; the Profiles or Device Management pane (its place depends on the macOS version) lists installed profiles, and profiles status -type enrollment in Terminal says whether the Mac is enrolled in device management. Windows and Linux have their own equivalents.
Keep employer software in its own space. A separate user account keeps its permissions and its background items away from your own. A separate device is better still, and it is reasonable to ask your employer to provide one.
Remove it after a session. Quit the client when you finish. If you only need it now and then, uninstall it, and remove any profile you no longer need. A profile that will not let you remove it is itself worth knowing about. If your work requires the profile or client, check your employer’s policy first: removing it can end your access and may breach terms you agreed to. Ask in writing instead.

What We Are Building: Keisen Schutzhund

Schutzhund is German for “protection dog.” Keisen Schutzhund is in development; it is not available yet. One of its planned features is meant to answer one question: who else has control of this computer?

It is designed to look for:

device-management enrollment and configuration profiles;
system extensions, which run alongside the operating system and can watch processes and files, and network extensions, which can see or filter network traffic;
trusted certificates someone added, which can let a proxy holding the matching key read encrypted web traffic from this computer;
managed browser policies;
background agents and login items that start without you;
which apps hold Screen Recording, Accessibility and Full Disk Access.

For each finding it will say, in plain words, what that item can do: a capability, not an accusation. It will mark what is new since the last time you checked. It will show the standard operating-system command behind every finding, so you can check it yourself instead of trusting us. And it will help you remove or contain what you find, by revoking a permission, removing a profile or moving software into a separate account, if you choose to.

What it will not do: it will not bypass, disable or defeat a control that is running. If your employer’s software blocks screen capture inside its window, Schutzhund will tell you that the software can do that, and since when. It will not switch it off. That is a feature, not a limitation. A tool that defeats controls puts its user at odds with the agreements they signed, and in healthcare with their duty to patients’ privacy. What was missing on October 23 was not a way around the control. It was knowing.

Schutzhund is designed to run on your computer and report to you. It will show what it found and how it looked; it will not certify a computer as clean.

Request Access

Keisen Schutzhund is in development and not available yet. Like KeisenVPA, its status is “request access”: tell us what computer you use and what worries you, and it will shape what we build first.

Request access to Keisen Schutzhund · About Keisen Schutzhund →

Seeing Comes First

October 23 was my last day practicing medicine in the United States. The screenshot was not the heaviest reason; it was the last one. And the only reason I noticed is that I had built something that depended on it. Most people in that position will simply notice, one day, that something no longer works, and not know why.

The remedy starts with being able to see: who else has a hand on this computer, what that hand can do, and what changed since yesterday. After that, the decision is yours, as it should have been all along.

Posted on October 24, 2026 by omarmetwally · 1 Comment

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 October 23, 2026October 23, 2026 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

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