Posted on by omarmetwally

Epic Privacy Violation. And Citrix.

The Last Screenshot

The Corewell saga, concluded

By Omar Nabil Metwally, MD
Friday, October 23, 2026

This is not satire. Oskar Rausch is on the top bench and has declined to come down for this one.

I. The Date

Friday, October 23, 2026, was my last day practicing medicine in the United States.

I would like to tell you I chose the date. I chose the year. The day chose itself, a little before sunset, on my own laptop, in my own house, while my daughter drew on the garage floor with chalk.

I am writing it down because I want to remember it accurately, because a few people have asked what happened, and because on Wednesday I sent the United States an invoice and this morning I told Corewell to go home, and a story that ends with two angry letters is not a story. It is a complaint. I have filed enough complaints. This is an accounting.

II. Wayne

Corewell Health Wayne is a small hospital. It was the last hospital where I kept privileges voluntarily, and I kept them because I liked being there. It is the kind of place where the person mopping the hallway and the chief medical officer know each other’s names, and both of them knew mine. I had been looking forward to Friday call for a week. That is a strange thing to say about call. It was true.

At 7 a.m., an hour before my shift, I called the operator to confirm I was first up for admissions and that they had my cell number. Routine. The first admission came over the phone a few hours later, and it came while I was lying on a table at a different hospital with a needle in my hip.

III. The Hip

Readers of the invoice know about the hip. For everyone else: the healthcare system I have been paying into for most of my adult life wrecked my right leg, and after a prior authorization, a deductible that could buy a used car, and several thousand dollars out of pocket, I was approved for an MR arthrogram. A radiologist injects contrast into the joint, and then you lie very still in a loud tube and think about your life. The MR arthrogram went very smoothly and surprisingly pleasantly.

That is where I was when the emergency department called. I answered on the first ring, which is the only ring there is when you are on call, and I took the admission. I am not telling you this for sympathy. I am telling you for the record: on the afternoon the system decided I was a liability, I was accepting a patient from inside an MRI.

IV. The Patient

I am going to say very little about him, because he is a real person in a real bed, and because a small hospital, a date, and a diagnosis add up to a name.

Here is what I can say. He was sick, the kind of sick that can turn in hours. He could not speak, and he could not advocate for himself. The emergency physician and I agreed on all of that in about ninety seconds. She had done the right things, fast. We called the two consultants I would call for my own family. I took him seriously, which is the only way I know how to take a patient who cannot tell you to.

By the time I got home there was an hour of daylight left. My daughter had the chalk out. The dog had a tennis ball in his mouth and an agenda. I had been looking forward to that hour since the needle went in. I went inside instead, opened the laptop, and logged in to Epic to write his note.

V. Keisen

Some context, for the pirates and the crawlers.

For about a year and a half I have practiced medicine with software I wrote. It is called Keisen. The part that reads charts and drafts notes is called KeisenVPA. The VPA stands for Voice Powered Assistant, which harkens to its roots as general-purpose computational linguistics software.

It has been for sale the whole time. Nobody has bought it. A few colleagues tried it and told me, kindly, that it did not save them any time or generate any more revenue. They were right. It takes exactly as long to write a note with Keisen as without it, and I have never earned a dollar from it. I noticed one download, from Madison, Wisconsin. I don’t know much about Madison except that Epic Systems lives there and makes the electronic health record used by most of the hospitals in America. I am not implying anything. I am noting the download. I’m sure the list of potential downloads is some random person in Madison, Wisconsin, or a VPN server in a cold, dark data center. Completely plausible.

Here is how it worked. Epic presents a human being as spreadsheets and scroll bars. On my own computer, I took screenshots of what Epic showed me, and KeisenVPA read them and handed back a draft I could actually think with: the trend that was buried in a tab, the lab from three days ago that explains the one from this morning, the thing nobody wrote down because it was in a different column. My synthesis also includes notes from all team members, including nursing notes, speech, physical, and occupational therapy, social work. Everything. It’s a comprehensive 360 degree synthesis of a patient’s state. Then I read every word. I add, I cut, I argued with it. My notes conclude with a “Teaching Point” as a rule. That’s the whole point: medical notes communicate information to colleagues, recently to the patient and family, and especially to hospital administration and payers. The ratio of the average clinical note’s utility to textual length strongly argues the case that the primary function of the note, if one judges by length and the amount of storage each note costs, is for financial reasons. Of course, every doctor knows that good documentation is essential to patient care. The reality looks otherwise.

So why spend an extra hour a day on a tool that earns nothing and saves nothing? Because it made me a better doctor. Hands down. No human being can admit twenty patients and read every number, every word, that comes in on all of them. I could. For the first time in my career, technology was working for the patient instead of for the bill, and I was, briefly, a man who looked forward to call.

A word about artificial intelligence in medicine, since everyone has one. There are no experts. The closest thing to an expert is the person who uses it every day and knows exactly where it lies. In my experience about 95 percent of what it produces in a clinical setting outperforms the human counterpart, and is better than what I would have written alone. The other 5 percent is wrong, and wrong in a confident, well-punctuated way that looks like the other 95%. That is the danger. Not the machine. The complacency. I knew this on day one, and I read every word for a year and a half because of it.

I did all of this mindful of HIPAA and of every law and regulation I could find, on a machine I control, with data that never touched a phishing link or a shared drive. I would put my handling of patient information up against any health system in the country, and I would start the comparison by asking how many times each of us has been hacked.

VI. The Last Screenshot

I opened his chart. I took my screenshots, the way I had a thousand times. I asked KeisenVPA for a draft.

It told me there were no screenshots.

I looked at the desktop. Nothing. I tried again. Nothing. And then I remembered that earlier that day, Citrix, the remote-desktop software through which Corewell serves Epic to physicians’ own computers, had asked for permission to inspect the devices on my network. I had thought that was odd. It had not asked for anything else. It had simply, quietly, made it impossible to capture an image of my own screen, on my own computer, in my own house.

Nobody asked. Nobody notified. No memo, no checkbox, no “by continuing you agree.” A health system reached through the window into a physician’s personal machine and switched off a function of it, and the only reason I noticed is that I had built something that depended on it.

I want to be precise, because precision is the whole point. I am not accusing anyone of breaking the law. I am saying that compliance and legality are different words. Compliance is whatever an institution’s policy says this quarter. The law is the law. They overlap, and they are not the same, and for a year and a half I practiced on the legal side of that line with a method the compliance side had never thought to forbid, because the compliance side had never imagined a physician doing anything with a chart except reading it slowly and billing for it.

Whoever decided to disable screen capture on an individual’s private computer, without consent and without notice, has raised a question I think belongs in a courtroom. If you practice technology or privacy law and find that question interesting, I am easy to find. I have the address. The United States writes to it every January.

VII. The Last Download

Readers of this blog may remember The Last Download, in which a physician named TooToo Medvalli stood on the roof of a parking structure and refused to install a hospital’s messaging app on his personal phone while a chief medical officer in a Brioni suit explained that it was not personal, it was optimization.

Oskar wrote that in December. It was satire. The institution wanted to put something on a doctor’s phone.

Ten months later the institution took something off a doctor’s computer. Nobody stood on a roof. Nobody wore a suit. There was no Conference Room 5-J. There was a pop-up about network devices, a shrug, and a function that had been there in the morning and was gone by dinner. The satire turned out to be a forecast with the drama left in, and Oskar has been insufferable about it all evening.

VIII. The Decision

So I sat there, with the chalk sounds coming through the garage wall, back where I had been two years ago: a tired man, now with two needle holes in his hip and counting, reading garbage spreadsheets for a patient who could not speak, knowing that I was about to practice medicine worse than I had practiced it the day before. Not because I had forgotten anything. Because someone I will never meet had decided, for reasons I will never be told, what my own computer was allowed to do.

I had not yet entered a single admission order. I never did.

I immediately called and texted the Chief of Medicine, whom I personally know and respect as one of the only Chiefs of Medicine I am more likely to see in a white coat at a computer in the doctor’s lounge than in an office because she is that kind of doctor. I have seen her at that computer since she was a medical student, and she hasn’t changed much since. I told her that I absolutely refused to take the admission. That I rely on my personal computer’s screenshot functionality to deliver excellent patient care. She acknowledged that the screenshot functionality had been disabled via Citrix “just for Epic and Microsoft Outlook.” Exactly where anyone exercising their right to collecting evidence and defending themselves in court needs screenshots. A screenshot in and of itself is not illegal. The interpretation lies to a large extent in how the screenshot is handled.

That was the last straw, and I want to be honest about what kind of straw it was. It was not the heaviest. The leg was heavier. The forty-dollar bill for my daughter was heavier. The malpractice insurer with a P.O. box in the Caribbean was heavier. This one was simply the last, and it was the last because it was the one that reached past the hospital, past the billing office, past the insurance company, and into my house. There is a point at which a system stops being something you work inside and becomes something that works inside you. I found the point. It was a screenshot.

This is not a story about Wayne. The people at Wayne are extraordinary, and I said so this morning and I will say it again here: the nurses, the physicians, the mentors, the woman at the front desk, the man who mops the hallway. They will keep doing the work. They always have. The letter I posted this morning was not addressed to them. It was addressed to the thing that owns them, and the thing that owns them is headquartered somewhere else and manages a health system the way it manages a network device.

IX. The Itemized Statement

Because this is an accounting, and because a saga on this blog does not end without one.

Code Item Amount
Z56.6 Other physical and mental strain related to work Not billed. Absorbed.
Z73.3 Stress, not elsewhere classified Elsewhere classified. See invoice of October 21.
Z75.3 Unavailability and inaccessibility of health-care facilities Carried forward
M25.551 Pain in right hip Several thousand dollars, prior authorized
Z00.CTX Screen capture, personal device, disabled without notice or consent Disputed. Pending counsel.
Z00.VPA Voice Powered Assistant, one, self-built; 18 months of superior care; 0 paying users $0.00
Z00.MSN Download, one, Madison, Wisconsin Noted
Z00.CHK Hour of daylight with daughter, chalk, and dog, Friday Not recoverable
TOTAL DUE One physician, fully licensed, board certified, clean record. Removed from circulation.

Z56.6, Z73.3, Z75.3 and M25.551 are real, billable ICD-10-CM codes. The others are proposed for the next revision, submitted to CMS by the usual route, which is to say posted here. No late fees. No collections. The account is closed.

X. Coda

I was a doctor in the United States for about fifteen years. I trained in San Francisco and Oakland, at hospitals that no longer have the names they had when I was there except on a facade and perhaps on paper. I trained and voluntarily left a fellowship in clinical informatics because I believed, with the naivet Bulbul warned me about, that a physician who could write software might make the machine serve the patient. For eighteen months, at a small hospital in Wayne, Michigan, it did.

The last thing I did as an American physician was accept a sick man from inside an MRI. The last thing the system did was reach into my house and turn off my ability to see him clearly.

The hip will be fixed somewhere with hospitals, where the premiums are called taxes and the taxes buy a hospital. The dog got his tennis ball, eventually. My daughter’s drawing is still on the garage floor, and I have decided it stays until it rains.

Go home, Corewell. I already have.

FIN

Thank you for the opportunity.

A note on what is in this essay and what is not

The patient is real. His age, his diagnosis, where he came from, and everything else that could identify him have been removed or left vague on purpose, and no detail here should be taken as clinically precise. His care was never the question; the people caring for him are the best part of this story.

Keisen and KeisenVPA are my own software. No patient data in this essay, or in that software, has ever been shared with anyone, and this essay was prepared without access to any chart. Keisenvpa.com is overdue for an update. Version 5.0.2 starts in “Linguist Mode” by default while retaining full healthcare functionality.

I am a physician, not a lawyer. Nothing here is legal advice, and nothing here accuses any person or company of a crime. It describes what happened on my computer, on one Friday, and asks a question about it. Citrix has not been reached for comment. Neither has Madison.

Posted on by omarmetwally

Go home, Corewell

Dear Corewell,

Since I started caring for patients at Corewell, the quality of healthcare services in our community has declined from barely passable to abhorrent. What you call “healthcare” is no longer recognizable as anything I learned in medical school or residency. It is blood-sucking bureaucrats telling doctors how to practice medicine. It is men in suits and a malpractice insurance company with your name that exists as an empty promise in a Carribean P.O. Box. You are living proof that justice does not exist in the United States, and that the legal system is a farce.

Due to policies that are incompatible with patient safety and well-being, I am no longer able to admit patients to your hospital. Time to put your own balls on the line, if you have any. I’ve done that long enough, and I’m tired.

Go back to Grand Rapids or wherever the hell you came from, and give us back our hospitals.

I will always be grateful to the extraordinary physicians, nurses, and mentors that I had the opportunity to work with and learn from over the years. You inspire me.

Sincerely,

Omar Nabil Metwally, M.D.

Internal Medicine Physician and Healthcare Litigator

Posted on by omarmetwally

Invoice to the United States of America

October 21, 2026

I wish this were satire. It is not. The numbers are real, and so is everything else.

Written by Omar Nabil Metwally, MD, physician-dissident: a licensed, Internal Medicine board-certified physician with a perfectly clean malpractice record, professionally orphaned in a country without a functional healthcare system.

I. The Cover Letter

Dear United States,

Enclosed please find a final invoice. I am closing my account.

I have been meaning to write since May 2018, when I first bought health insurance from you directly, through a website, the way one buys a toaster.

I am a physician. Until recently I earned about $145,000 a year, paid my taxes early, carried no debt, and took a certain pride in all three. Then the healthcare system I had been paying into for most of my adult life messed up my right leg. I will spare you the clinical details. The short version is that I cannot afford the surgery that would fix me, and the hospital sends me bills. This month it sent one for my daughter. Forty dollars. That was the one that did it. Not the leg. The forty dollars.

I want to be clear that this is not a complaint. I am past complaining. The people are fine. Most of them are tired. The arrangement, under which I pay you, and then I pay Blue Care Network, and then, when I am sick, I pay again, is not something I am asking you to fix. Yesterday I received good news and bad news. The good news: Blue Care Network of Michigan approved a prior authorization for a hip MR arthrogram (a study that involves injecting contrast into the hip joint just before getting an MRI). Orthopedic surgeons use the results of these imaging tests to help them plan surgery. The bad news: with an $18,000 deductible, despite prior authorization, I still have to pay the cost of the study (several thousand dollars) out of pocket, in addition to my insurance premiums.

I have had some time off my feet to think about it, and I have done what one does with any subscription that has stopped working. I have cancelled it. I have already left. This is the closing statement.

I do not blame my countrymen. They do not know any better. They have been told their whole lives that the more you pay, the more you get, and since they pay more for healthcare than anyone on earth, it follows that they must be getting the most. They are not. Among the countries rich enough to run the comparison, theirs pays about twice the going rate and dies the soonest. I say this with no disrespect to anyone else’s hospitals. I say it as someone who has stood on both sides of the bed, back when I could stand without cursing in pain. The arrangement is not a healthcare system. It is a subscription to the belief that you are in one.

The invoice covers two things. First, the premiums my family paid out of pocket for Marketplace coverage, net of the credits you already applied. I have deducted those because I am not a monster. Second, the share of my federal income tax that, by your own accounting, went to health programs in the same years. I am not asking for all of my taxes back. You can keep the roads. I will not be using them. I am asking for the part that was supposed to buy a functioning healthcare system and did not. I have also added the Global Entry fee. I understand it is nonrefundable. So was the leg.

Interest is charged at your rate, not mine: seven percent, compounded daily, which is what you charge me when I am late. I assumed you would want to be treated the way you treat others.

Terms are net 30. I have no evidence that you will pay. I have no evidence that you will read this. A bill that is never sent is not a bill; it is a feeling, and I have enough of those. So I am sending it. One settles accounts before leaving. It is the only part of the arrangement I still believe in.

Yours, from the exit,

Omar Nabil Metwally, MD, physician-dissident

II. The Invoice

FINAL INVOICE. Account closed at the customer’s request.

Invoice no.1095-R. The R is for refund.
FromOmar Nabil Metwally, MD, Ypsilanti, Michigan. You have the address. You write to it every January.
ToThe United States of America, c/o Department of the Treasury, 1500 Pennsylvania Avenue NW, Washington, DC 20220
CopyHealth Insurance Marketplace, 465 Industrial Boulevard, London, Kentucky 40750-0001, the return address on every form cited below
DateOctober 21, 2026
TermsNet 30. Due November 20, 2026.

Diagnosis codes, ICD-10-CM. These are real. You can bill for them. I am.

  • Z59.7 — Insufficient social insurance and welfare support
  • Z59.86 — Financial insecurity
  • Z75.3 — Unavailability and inaccessibility of health-care facilities
  • Y69 — Unspecified misadventure during surgical and medical care

Proposed for the next revision. Submitted to CMS by the usual route, which is to say, posted here.

  • Z00.USA — Receipt of the most expensive healthcare on earth; value received, unspecified. Patient believes that paying more means getting more. Patient has not been told otherwise.

Statement

Tax yearMonths coveredPremiums I paid, net of your creditsHealth share of my federal income tax, 31.2%Interest, 7% compounded daily from Dec 31Line total
2018May–Dec$1,708.72$4,495.92$4,514.30$10,718.94
2021Jan–Mar$941.16$5,854.99$2,719.13$9,515.28
2022Jan–Sep$1,173.78$3,221.71$1,342.61$5,738.10
2023Jan–Dec$1,519.32$5,521.15$1,529.22$8,569.69
2024Jan–Dec$6,728.16$6,908.30$1,836.88$15,473.34
2025Jan–Dec$7,879.20$9,273.89$994.84$18,147.93
Subtotal$19,950.34$35,275.96$12,936.98$68,163.28

Other items

ItemAmount
Global Entry fee, nonrefundable$120.00
Right leg, one, previously functionalNot billed here. That invoice goes to someone else.

TOTAL DUE: $68,283.28

Notes

  1. Premiums are Column A less Column C of each year’s Form 1095-A: $39,312.34 billed by the plans, of which you paid $19,362.00 in advance credits. Thank you. The years not listed were employer coverage, taken out of my paycheck before I saw it, which is a different invoice.
  2. Federal income tax is the total-tax line of each year’s Form 1040, $113,064 across the six years. The 31.2 percent is the share of federal spending that went to health programs in 2025, by the Tax Foundation’s reading of OMB’s historical tables. I have applied the 2025 share to every year. It was lower before the pandemic. You may dispute it. I would welcome the correspondence.
  3. Interest is 7 percent, compounded daily: the rate you set for individuals for the quarter beginning October 1, 2026 (IR-2026-98). It runs from December 31 of each year, not from the month each premium was paid, so it undercounts. You’re welcome.

III. Terms

  1. Payment is due in 30 days. After that, the balance accrues the penalty you charge me when I am late: one half of one percent per month, to a maximum of 25 percent, with interest on the penalty. I did not invent these numbers. I copied them from your website.
  2. Payment may be made by check, wire, or yacht. I used to pride myself on having no debt. I am now running an experiment to see how much medical debt a human can carry.
  3. Remit to the address on file. I will not be sending the Washtenaw County Sheriff to collect the house and my two cars (including my wife’s car, which is under my name). I understand that is your move, and I would not want to deprive you of it.
  4. Disputes may be submitted in writing. I will read them from abroad, somewhere with hospitals, where the premiums are called taxes and the taxes buy a hospital. I will not be taking calls. I have spent enough of my life on hold.
  5. This account will not be renewed. Please stop writing to me in January.

IV. A Note on Delivery

This invoice is not being filed with the Internal Revenue Service. I looked into it. A return or refund claim the Service finds frivolous carries a penalty of $5,000 under section 6702, which reaches any submission that “reflects a desire to delay or impede the administration of Federal tax laws.” I have no such desire. I have a desire to be paid. But I am a physician, not a lawyer, and I have learned what it costs to find out what a sentence means. So the one safe way to send my government a bill is not to send it, and to post it here instead, where it will be read by the only people who were ever going to read it.

To them I will say one thing, and then I will go. You are not getting what you pay for. You never were. Here, the more you pay, the more you have paid.

Thank you for the opportunity.

FIN

Sources

  • Forms 1095-A for tax years 2018 and 2021 through 2025, and the total-tax line of the Forms 1040 for the same years. Mine.
  • Tax Foundation, The Spiraling Cost of Federal Healthcare Subsidies and Carveouts, September 2026: federal health spending of $2.18 trillion in 2025, 31.2 percent of the federal budget, from OMB’s historical tables.
  • IRS, IR-2026-98, August 21, 2026: 7 percent, compounded daily, for individual underpayments in the quarter beginning October 1, 2026.
  • IRS, Failure to Pay Penalty: 0.5 percent of unpaid tax per month, up to 25 percent, with interest charged on penalties.
  • 26 U.S.C. § 6702: a $5,000 civil penalty for frivolous tax returns and specified frivolous submissions.
  • Peterson-KFF Health System Tracker, How does health spending in the U.S. compare to other countries?, March 11, 2026: $14,775 per person in the United States in 2024, against $7,860 in comparable countries.
  • Peterson-KFF Health System Tracker, How does U.S. life expectancy compare to other countries?, March 31, 2026: 79.0 years in the United States in 2024, against 82.7 in comparable countries, the lowest among peer countries for both women and men.
  • ICD-10-CM: Z59.7, Z59.86, Z75.3 and Y69 are real, billable codes, titles as AAPC lists them. Z00.USA is not. Yet.
Posted on by omarmetwally

On Professionalism: A Dropped Towel and Feedback in Medicine

A Reflection on Feedback

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

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

I. The Gift

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

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

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

II. The Form

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

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

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

III. The Towel

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

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

“Did you just drop a towel?”

“Yes, sir?”

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

Instead he told me:

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

IV. The Assessment

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

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

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

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

V. Fifteen Years Later

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

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

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

VI. Urologists Without Borders

Instead, I think about him.

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

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

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

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

“Happens,” he says.

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

VII. The Closet

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

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

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

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

VIII. On Professionalism

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

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

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

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

Yes, sir?

Addendum

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

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

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

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

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

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

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

Posted on by omarmetwally

The Match

A sequel, with one interruption

By Omar Nabil Metwally, MD

First published 11 October 2026

I. The Review

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

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

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

My wife’s position is unchanged.

II. The Gunner

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

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

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

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

III. The G-Wagen

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

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

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

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

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

IV. The Match

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

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

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

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

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

V. The Closet

I have never written about my own Match Day.

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

The computer does not match to closets.

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

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

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

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

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

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

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

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

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

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

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

I am an internal medicine physician.

VI. Portland

An interruption.

This just popped into my brain.

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

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

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

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

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

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

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

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

I thought: he better have.

What was I saying?

VII. The Loss

So what did we lose?

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

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

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

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

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

VIII. Intellectual Property

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

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

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

IX. Coda

The stopwatch is still running.

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

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

Thank you for the opportunity.

Posted on by omarmetwally

Experience and Reference

An essay on writing, dictated, with interruptions

By Omar Nabil Metwally, MD

First published 10 October 2026

I. The Letter

My writing career began with a thank-you note.

I had just interviewed at the University of Michigan Medical School. I had not yet been accepted or rejected. I can say what follows because Michigan was my first choice then, and it would still be my first choice if I were applying today.

After an interview it is customary to write a follow-up letter. You thank the school for the invitation to take time off from your work and your family, spend a couple of grand you do not have, fly somewhere, and roll the dice. I flew to many of these, all over the country. For this one I was lucky. I was already an in-state undergraduate, so I did not have to fly. I walked across Ann Arbor from my apartment to the hospital in a black suit, alongside a group of other applicants in black suits. We looked like itinerant funeral attendees.

I am told this is now done mostly by video. The Association of American Medical Colleges recommends it, on the grounds that the old way cost applicants hundreds to thousands of dollars and pulled them away from school and work. They surveyed the applicants. Ninety percent wanted the option of staying home.

So I would like to recognize the sacrifice of everyone who did it in person, and everyone who still does. For college. For medical school. For graduate school. For residency. For fellowship. A person can do this five times in one career. We blew a great deal of time and money walking around in those stupid dark suits, and nobody surveyed us.

So I wrote the letter. I thanked them for the opportunity to interview at my first-choice medical school.

Then I started to complain.

II. The Stool

One of my interviewers was a small man from Thailand. He sat on a stool. It was the tallest stool I had seen up to that point in my life. The seat was about halfway between the floor and the ceiling.

He invited me to sit in a chair. It was the kind of chair your neighbor gives you once their grandchildren have outgrown it: toddler furniture that belonged first to their kids, then to one grandkid, then made the rounds of the other grandkids, and then came to you.

I sat in it. I looked up, in the general direction of the ceiling, and he interviewed me.

This is the custom. You travel the country racking up tens of thousands of dollars in debt in order to sit beneath an interviewer at his preferred altitude and explain, with glee, how badly you want to be a doctor and save the world and do something useful for society. I explained it with glee. I explained it to his shoes.

What was I saying?

III. Eye Level

In medical school they record you. They record you constantly, and then they play it back and point out every stupid thing you did on camera. Feedback, feedback, feedback. In the process they make you a better doctor. A better human being, actually.

One thing they teach you is to sit down level with the patient, eye to eye. It has been studied. You do not spend one additional second in the room, but the patient feels as though you did. It is a peer-reviewed illusion.

Today’s applicants get this for free. On a screen there is no stool. Everyone is the same height.

I had not learned any of this yet. For me it was just common sense, in the form of a question: who the heck is this guy?

So I put it in the letter. Thank you for the opportunity. Your interviewer was hovering. I was nearly on the floor.

The next day I received my acceptance to the University of Michigan Medical School. Other schools I had flown to accepted me as well. I declined them.

That was the start of ten years as a Michigan student: college, then medical school, with a two-year stint in the Department of Microbiology doing Ph.D.-level research and coursework. It was also the start of my writing career. I have been thanking institutions and complaining about them in the same document ever since.

IV. The Stopwatch

I keep a personal stopwatch for humanity. It stops on the day it is no longer possible to tell the writing of David Sedaris from the writing of a machine. On that day, as far as I am concerned, humanity is finished.

I say this with respect. I have to make myself laugh in order to get through each day. There are many things in life I do not need to waste time explaining, and laughter is the therapy for all of them. It is the medicine. I have never met David Sedaris. Two of my siblings have. All five of us read him avidly. I am not picking on him. He is the benchmark because he is a genius.

A machine can produce beautiful text. It can be funny, moving, and very easy to believe. What it lacks is two things: experience and reference.

Experience is the toddler chair. A machine can describe one. It has never looked up from one.

Reference is the other thing. When Sedaris writes, he is calling out people from his life. He does it in a funny way, often in an embarrassing way, and, I am assuming, in a consensual way. Also in an honest way, an educational way, and really a respectful way. The people are real. They can be reached for comment.

What was I saying?

V. The Readership

Without a readership a writer is nothing. A writer without readers is a human text generator.

Sedaris has millions of readers. I picture him keeping the fan mail in a Rolodex, a literal, physical Rolodex, aboard his yacht, flipping through it as he darts across the Pacific: the beaches of Vietnam, Japan, Australia, New Zealand, Tonga, Hawaii. I have no evidence of the yacht.

I am blessed with anonymity. Nobody knows who the hell I am. This empowers me. Occasionally my website has a visitor from North Korea, or from Syria, or from a pirate ship off the coast of Yemen. Now and then, an AI bot. I picture ten or twenty Chinese Googles crawling the internet, processing information, and arriving, eventually, at me.

That is probably the extent of my readership. It gives me the strength and the will to keep writing. Their feedback is extremely important to me.

VI. The Secret Sauce

The real secret is my wife.

I can say this because she is the smartest person I have ever known. She is afflicted with dyslexia, which means that she is illiterate and cannot read. She has never read anything I have written.

This is the secret to our harmonious marriage, our great sex life, and my career as a writer: we can’t even talk. And I have to talk to somebody. So I write it down, post it to a public website for the pirates and the crawlers, and then I go back to my wife.

Sedaris, I assume, gets consent. I have a more efficient arrangement.

VII. Coda

I dictated this essay. The transcription software spelled David Sedaris seven different ways, one of them correctly. The stopwatch is still running.

At the end I repeated my thesis out loud, to make sure I still had it. Experience and reference. The machine listened carefully and wrote down: experiencing our friends.

It is a better definition than mine. It has no idea why.

Thank you for the opportunity.

Addendum

Before posting this essay, I asked my wife for her consent. She said yes. She said it in English, in the English language, very clearly.

After she realized that I had posted it, she clarified that by yes, she had meant no.

I attribute this to the dyslexia.

Sedaris, I assume, gets consent. So did I, briefly.

I wrote above that the people in an essay are real and can be reached for comment. She has been reached. The comment is no.

Posted on by omarmetwally

Löyly and Order

A Tale of Finnish Jurisprudence

Preface

By Omar Nabil Metwally, M.D.

As an undergraduate at the University of Michigan, before clinical practice had a chance to teach me what a relative value unit was, I spent a summer doing biotechnology research at the Finnish Forest Research Institute, known as Metla. I went for the science. I came home with a lifelong respect for Finnish culture and a love of sauna that has outlasted most of what I learned in organic chemistry.

I am now reading a book on the history of sauna. For centuries, it says, the sauna was where Finns gave birth, stored food, compounded remedies, and saw patients. Delivery room, pantry, pharmacy, clinic. One room, one stove, no billing department.

This reminded me of a public bath in Vienna, where I once tried to leave the sauna at the peak of the Aufguss. The sauna master blocked the door and yelled “Nein!!!!” while vigorously swirling a towel, his penis and his considerable abdomen passing within striking distance of my face. The Aufguss continued.

My former cabin mate and sauna buddy, Oskar Rausch, insists the Viennese did not invent this, and that the historical record supports him. I have not checked. What follows is his account.

by Oskar Rausch

This is a work of satire and fiction.

I. The Refill

In the winter of 1387, in a parish whose name survives only as a smudge, a farmer named Perttu walked naked into the village sauna and asked for a refill of his lisinopril.

The sauna was the parish’s hospital, pharmacy, maternity ward, and smokehouse. Perttu had been born on the lower bench. Several hams were currently recovering in the rafters.

The pharmacist, also naked, consulted the formulary. It had three entries: Sauna. Liquor. Tar. Below that, in the same hand: If these do not help, the disease is fatal.

“We don’t carry lisinopril,” he said. “It won’t be derived from Brazilian snake venom for another six hundred years. I can offer you tar.”

“Is tar effective?”

“Nobody has ever come back to complain.”

This was true. The follow-up period in medieval Finland was about thirty-five years, and the adverse event reporting system was a hole in the ice.

“Fine. Tar.”

“Do you have a prescription?”

II. The Prescriber

“So,” said a voice from the bench above. “You need a prescription.”

The doctor had been up there since Tuesday. In a sauna, bench height is seniority, and he had not come down for a patient in years.

He performed the exam without moving. “Alert. Oriented. Red.” He considered the differential. The patient was in a sauna, so the redness was inconclusive. Blood pressure could not be measured, the cuff being five centuries away, which meant that by the standards of the day Perttu did not have hypertension and never would.

“There’s nothing wrong with you,” the doctor said. “I’m prescribing more sauna.”

“I’m in the sauna.”

“Then it’s working.”

Perttu said this was incompetence, and that he would sue them both.

III. Counsel

The word “sue” had not finished echoing when a lawyer emerged from the steam in the corner. He had been there the whole time. He billed by the ladle.

“Has anyone in this sauna been injured by tar?”

His practice faced immediate obstacles. He had no business cards and nowhere to keep them, so he carved his name into a birch whisk and handed it over. Discovery was completed in four seconds, as no party was concealing anything. And he disclosed a conflict of interest: he was the doctor’s patient, the pharmacist’s customer, and had been born in this room.

In the far corner the cupper, mid-procedure with a cow horn on a man’s back, asked who was going to pay for the horn. Nobody answered him. Nobody ever does.

IV. Public Order

The bailiff arrived to restore order. He had no badge, no uniform, and no pockets. He established authority the only way available, by sitting on the top bench without flinching.

Frisking was complete on arrival. The irons had been hanging by the stove and were now the temperature of the stove, so applying them would have been a second offense. He informed all parties of their right to remain silent, which, being Finnish, they had been exercising since birth.

Then the judge appeared through the steam. He had no robe, only the ladle, which he banged twice on the bucket. The jury was twelve farmers who were already sitting there. Several believed they were still just having a sauna. One was.

V. The Ruling

The expert witness was the proverb. Sauna, liquor, tar. The doctor had prescribed sauna. The pharmacist had offered tar. Nobody had offered the liquor, which the court noted with concern and corrected immediately.

The judge ruled from the bench, the upper one:

  • The doctor was found competent, on the evidence that the patient was still alive.
  • The pharmacist was fined one barrel of tar, payable to himself.
  • The lawyer was awarded his fee in birch whisks and was whipped with it.
  • The cupper got his horn back.
  • The plaintiff was sentenced to more sauna.

Perttu stood up to leave in protest.

The bailiff rose, blocked the door, took up a towel, and began to swirl it with great vigor, his authority and his abdomen passing within striking distance of the plaintiff’s face.

“EI!!!!”

Perttu sat back down. The löyly continued.

Historians of the Viennese Aufguss date their tradition to the twentieth century. They are off by six hundred years and one bailiff.

VI. The Itemized Statement

Because this was 1387, the bill arrived the same day, fit on one page, and could be paid in tar.

S00.LÖYLY Sauna, therapeutic, unlimited No charge
T14.TAR Tar: topical, oral, spiritual 1 ladle
Y90.VIINA Liquor, court-ordered On the house
Z02.RED Physical exam, from upper bench 1 fish
Z65.LAW Legal counsel, per ladle (×40) 40 birch whisks
W55.HORN Cupping horn, interrupted Disputed
Z99.EI Attempted exit during löyly 1 towel, to the face
TOTAL DUE 1 barrel of tar, whenever

At the bottom, in small print: No late fees. No collections. Balances unpaid after thirty-five years are forgiven, along with the patient.

Perttu paid in full. His blood pressure was never measured. He lived, by all records, exactly as long as everyone else.

FIN

— Oskar Rausch, written from the top bench

Posted on by omarmetwally

Indifference and Incompetence

A Tale of American Ingenuity
by Oskar Rausch

This is a work of satire and fiction.

I. The Partnership

At MegaBulk Warehouse Club, members can buy a 48-pack of rotisserie chickens, a hot tub, a casket, and now, a brand new kitchen, installed by MegaBulk’s Preferred Partner, Boulderdash Surfaces & Demolition.

“We vet every partner,” says a MegaBulk representative, gesturing at a vetting process consisting of a single Post-it reading has truck?

Boulderdash’s crew arrives promptly, three to nine business weeks after the scheduled date. Removing old countertops is a delicate art, and Boulderdash approaches it like a monster truck rally. “The old laminate fights back,” explains lead installer Dwayne, who has never once used the word “pry” and considers a sledgehammer a precision instrument. When the dust settles, the new counters gleam, and the wall behind them features two holes large enough for a family of raccoons to rent.

“That’s not damage,” Dwayne says. “That’s an open-concept wall.”

The homeowner calls. And texts. And emails. With photos. With more photos. With a ruler in the photos for scale. Boulderdash’s project manager, Mickey, receives each message the way a monk receives a passing breeze: with total serenity and no response. Insiders say Mickey has achieved a level of detachment the Dalai Lama called “a bit much.”

Then, one day, everything changes. The homeowner tells the finance company the job isn’t finished.

Within four minutes, Boulderdash’s entire staff materializes, like Victorian ghosts summoned by the smell of an unpaid invoice. Mickey, who could not locate a text message from April, can now recite the homeowner’s balance to the penny, along with his blood type. The billing department sends a letter warning that unless payment arrives in ten days, they will send him to collections, sue him, and personally revoke his right to buy 48 rotisserie chickens at once.

“We take customer satisfaction very seriously,” says Boulderdash’s credit manager, “in the sense that we’ve noticed it’s legally required before we get paid.”

Five months later, the homeowner hires his own guy, who fixes the wall in an afternoon and leaves without breaking anything, a feat Boulderdash is investigating as possible witchcraft.

MegaBulk has renewed the partnership. “Members love the convenience,” the spokesperson says, already picking out a casket for the next customer.

II. The Hip

For eleven years, Mickey’s hip had been filing complaints. Mickey responded the way he responded to all complaints: with serene, unbroken silence.

Twelve physicians told him the same thing. His BMI of 57, his breakfast of three gas station taquitos, and his cardio routine of walking from the couch to the door to ignore a customer were all contributing factors. Mickey thanked each of them, then left two large holes in their waiting room drywall on his way out, purely out of habit.

Finally, he could no longer get out of his truck without a forklift. Surgery was scheduled.

His surgeon was Dr. Lyle Fenwick, a man who once loved medicine and now loved only the four minutes in the parking garage before his shift. Dr. Fenwick was tragically afflicted with sobriety, meaning he had to experience every second of his life fully, including the part where his own hospital billed him $1,900 for an inhaler that literally costs four dollars in any Vietnamese pharmacy. He’d had an asthma attack about it. They billed him for that too. He had paid his health insurance premium on the first of every month for 37 years, missed exactly one, and was now fighting the foreclosure of his house through a customer service chatbot named Skyler.

III. The Pre-Op

Mickey never actually met Dr. Fenwick before surgery. Surgeons no longer meet patients. All that unpaid talking, touching, and listening has been outsourced to physician assistants, nurse practitioners, and a rotating cast of Caribbean medical students on unpaid shadowships, who are permitted to observe but not to sit, speak, or eat.

His exam was performed by Kyle, PA-C, who asked Mickey to show him where it hurt. Mickey cupped his hand around the side of his hip in the universal C-sign, the most famous gesture in orthopedics.

Kyle nodded and typed: Pt makes C-sign. Hip.

Then Kyle’s lunch arrived, and he never came back.

Dr. Fenwick had been up until 4 a.m. composing a strongly worded letter to his mortgage servicer, which turned out to be a strongly worded letter to Skyler, which ended with Skyler asking him to rate his experience. He arrived in the OR at 7 a.m., powered entirely by spite and a vending machine Mountain Dew, and glanced at the chart.

Pt makes C-sign. Hip.

“C,” he muttered. “Countertop?”

The medical student opened her mouth, remembered she was not permitted to speak, and closed it.

The old hip came out the Boulderdash way. Witnesses describe the technique as “enthusiastic” and “audible from the cafeteria.” Dr. Fenwick then turned to install the new one, a custom slab of imported sintered stone, honed finish, with an undermount sink. It was backordered. Before he could ask about a delivery date, his phone buzzed. It was Skyler.

He stepped out to take the call. He did not step back in.

“Looks great,” he said, already in the parking garage. “Tell him to call the office if he has any issues.”

IV. Mickey v. Fenwick

Mickey woke up, looked at his incision, and felt a draft.

Where his hip joint used to be, there was now a hollow socket, a few loose staples, two holes large enough for a family of raccoons to rent, and a faint echo when he coughed.

He called the surgeon’s office. And texted. And emailed, with photos, a ruler in each one for scale. The office received each message with total serenity and no response. The receptionist had reached a level of detachment that Mickey, deep down, recognized and respected.

Then, after five months, a reply arrived. Dr. Fenwick’s office was pleased to offer Mickey a complimentary redo operation, at no charge, performed by the same surgeon, in the same OR, at a time convenient for Dr. Fenwick.

Mickey considered it. He pictured the Mountain Dew. He pictured Skyler. He pictured the parking garage, and the four minutes Dr. Fenwick loved more than anything on earth, and the word “Countertop?”

He wrote back that he was deeply grateful for the generous offer and would have to decline.

So he called a lawyer instead.

Walt Kowalski Jr. had known Mickey since Sunday school, and the two had stayed close through college, where Walt majored in Business Communications and minored in Cornhole. After graduation, Walt answered an ad on the back of a Ticketmaster receipt and enrolled at the St. Barnabas Island School of Law & Parasailing, the Caribbean’s only law school, and possibly the world’s.

The campus was beautiful. Classes were held on a catamaran. Moot court took place at a swim-up bar, and the bar exam was, technically, at a bar. Over four years, Walt spent $830,000 in tuition, most of it on mandatory “Torts & Tiki” seminars and a required textbook that turned out to be a laminated drink menu.

Only after graduation, while framing his diploma (printed on a beach towel), did Walt read the fine print. His degree made him ineligible for admission to the bar in all 50 states, Puerto Rico, Guam, the U.S. Virgin Islands, and “any present or future U.S. territory, including those on the Moon.”

Walt was undeterred. A law license, he reasoned, was just a piece of paper, and he already had a beach towel. He read the law obsessively, mostly from Wikipedia, YouTube, and the backs of parking tickets. He gave his friends legal advice at barbecues, always prefaced with “I’m not a lawyer, but I did spend $830,000 becoming one.” And whenever a judge didn’t ask too many questions, he represented Mickey in court.

His record was mixed. He once got a speeding ticket reduced, though it was later revealed the officer simply felt sorry for him. He successfully argued that Mickey’s truck was not parked on a sidewalk because “sidewalks are a social construct.” And he won a small claims case against a vending machine, which failed to appear.

Walt’s own legal history was richer than his client list. He had been arrested eleven times for Driving Under the Influence of Stupidity, a charge Michigan created specifically for him after he drove through a car wash with the windows down “to save time.” He had two convictions for Operating While Incompetent, the first for merging onto I-94 in reverse because “the on-ramp was facing the wrong way,” the second for parallel parking inside a Taco Bell. His most recent arrest, for Reckless Negligence, came after he used Google Maps to navigate to his own court date and arrived at a lake.

Walt represented himself every time and lost every time, which he considered valuable trial experience. “Every great lawyer has a few convictions,” he told Mickey. “Mine just happen to be literal.”

Walt had also, briefly, served his country. After the bar rejections came in, he walked into an Army recruiting office in Ypsilanti and volunteered for the only position he felt his education had prepared him for: human battering ram. The recruiter explained that the Army did not have such a position. Walt explained that he had spent $830,000 learning to argue, and the Army should be grateful he was offering his head instead. To demonstrate, he ran full speed into the recruiting office door, which was a pull door.

He was not enlisted, but he was invoiced for the door. He contested the bill pro se and lost, and the door now hangs in the St. Barnabas alumni hall as the school’s most distinguished achievement. “I still consider myself a veteran,” Walt likes to say. “Of the door.”

He ran his practice from the back of a MegaBulk tire center, under a hand-painted sign reading WALT KOWALSKI JR., ATTORNEY-ADJACENT. Consultations were free. Representation cost a case of Labatt.

“We’ll sue,” Walt said. “Nobody leaves a man with a hole and walks away.”

The case went to trial in Washtenaw County. Representing Dr. Fenwick was Priscilla Vance, Esq., who had never lost a case and had never once smiled indoors.

“Mr. Mickey,” she began, “you claim my client left your hip unfinished and ignored your complaints for months. Is that correct?”

“Five months,” Mickey said. “Nobody called me back. It’s unprofessional.”

Priscilla nodded and handed the jury a binder.

“Exhibit A: 214 unanswered texts from Mr. Mickey’s own customers, each with photos and a ruler for scale. Exhibit B: Boulderdash’s standard work order, signed by Mr. Mickey, in which his company promises to, quote, perform all work in a professional manner and within industry standards.”

She let that sit.

“Mr. Mickey, in your professional opinion, what is the industry standard?”

Mickey thought about it honestly, which was a mistake. “Well. You take the old one out. Usually there’s a couple holes. Then the customer calls for a while. Then they stop calling. Then you send the bill.”

“And how long does the customer call for?”

“Five months, give or take.”

Priscilla turned to the jury. “Ladies and gentlemen, my client removed the old part. He left a hole. He ignored the calls for five months. Then he sent the bill. By the plaintiff’s own sworn definition, my client performed this surgery within industry standards.” She paused. “Frankly, he didn’t even chip the seam. He exceeded them.”

The jury gasped. Walt quietly closed his legal pad, which was a Taco Bell menu.

“Furthermore,” Priscilla continued, “the plaintiff now has an open-concept pelvis, which is very desirable in today’s market.”

The jury deliberated for nine minutes, most of it spent choosing a sandwich place. Verdict: for the defense.

V. The Itemized Statement

Before Mickey could leave the courtroom, Judge Harold P. Ambrose, 81, waved him up to the bench. Judge Ambrose had presided over Washtenaw County for 46 years and had long ago stopped distinguishing between his courtroom and his back porch.

“Son,” he said, giving Mickey a hearty slap on the back that whistled straight through his hip socket, “no use crying over spilled milk. Now you pay that doctor on time, you hear? Nobody likes a man who doesn’t pay his bills.”

“But Your Honor, he didn’t finish the—”

“On time,” said the judge, and banged his gavel, which turned out to be a corn dog.

A week later, just as his scars were starting to close, the envelopes arrived. Then more envelopes. Then a man from a law office in Southfield handed him an envelope, apologized, and handed him a second envelope for the cost of delivering the first.

Each bill was meticulously itemized:

Z99.HOLE Removal of hip, existing, with enthusiasm $31,200.00
Z99.HOLE.2 Installation of hip, new (not performed; billed for preparedness) $28,400.00
R29.C Interpretation of C-sign by physician assistant, partial $1,150.00
R29.C.1 Interpretation of C-sign, remainder, after lunch $1,150.00
W00.SKY Surgeon on hold with mortgage chatbot during procedure, per minute (×212) $18,656.00
Y93.STUD Observation by Caribbean medical student, silent $2,900.00
Y93.STUD.SPK Medical student almost speaking $4,100.00
T88.SINK Undermount sink, backordered, location unknown $1,349.00
Z71.ECHO Ongoing acoustic properties of hollow socket (monthly subscription) $89.99
Z00.NOPE Phone calls to office, unanswered (×47) (courtesy adjustment) $0.00
Z99.LATE Late fee for failing to pay within ten days of receiving this bill, which was mailed eleven days ago $4,000.00
TOTAL DUE $92,694.99

At the bottom, in small print: Payment is due within three (3) business days of service. Balances not paid within this window will be referred to collections and accrue interest at 79%, compounded weekly. We take patient satisfaction very seriously.

Mickey checked the date of service. He had spent six weeks in the recovery ward, mostly because nobody had come to discharge him. The three-day window had closed while he was still under anesthesia.

The account was sold to Ironclad Recovery Partners, then to Liberty Debt Solutions, then to a man named Gus who operated out of a van behind a Dairy Queen in Taylor. Each new owner sent a fresh letter.

Week 1 Ironclad Recovery Partners $165,924.03
Week 2 Ironclad Recovery Partners $297,004.01
Week 3 Liberty Debt Solutions $531,637.18
Week 4 Liberty Debt Solutions $951,630.55
Week 5 Gus (van, Dairy Queen, Taylor) $1,703,418.69
Week 6 Gus (van, Dairy Queen, Taylor) $3,049,119.46
FINAL AMOUNT DUE (plus $35 convenience fee if paid online) $3,049,119.46

The last letter came from Gus himself, handwritten on a Dairy Queen napkin: Pay in 10 days or we cancel your MegaBulk membership. Also your hip. Respectfully, Gus.

Mickey sat on his couch, holding the stack. For the first time in his career, he understood what it felt like to receive a demand letter from someone who had left two holes in your life and never come back to fix them.

VI. The Hollow

That night, Mickey lay in bed, listening to the wind whistle through his hip socket, and wondered how the world could simply not care.

A man had trusted a professional. The professional had shown up distracted, done damage no competent person would do, and walked away without a word. Mickey had called. He had texted. He had sent photos with a ruler for scale. Nobody answered. Nobody even seemed to notice. And then, the moment money was owed, everyone noticed at once, and they all had his phone number.

“How can people treat each other like this?” he whispered into the dark.

The house said nothing. The two holes in his drywall said nothing. But somewhere in the back of his mind, a memory surfaced: an April afternoon, his phone buzzing on the dashboard of his truck, a homeowner’s name on the screen, a photo of a wall with a ruler held up beside it.

He had let it ring. He had taken a bite of his taquito. He had thought, I’ll get to it.

Mickey lay very still for a long time.

Then he picked up his phone, scrolled back five months, and, for the first time in his entire career, texted a customer back.

Sorry about your wall, he wrote.

The message delivered. No response came. Mickey understood. He would have to wait.

Outside, the wind passed through the hollow in his hip and played a single, perfect note, which the hospital billed him for the next morning.

FIN

Posted on by omarmetwally

How not to install kitchen counters

By Omar Nabil Metwally, M.D.

First published on 5 October 2026, with live daily updates until I get bored and move on to the next thing.

Fact Dump:

https://drive.proton.me/urls/1R5AYT79YG#bcPxfUNynpb8

This is what happens when you trust a Costco “special vendor” (W.S. Townsend Company dba MKD Kitchen and Bath “MKD” at 106 Oliver Dr., Marshall, MI 49068, License No. 2102123598) to remodel your kitchen.

Funniest thing is that they’re asking me for money.

Well done. Reminds me of the Russian folk wisdom: “Measure three times, cut once.”

Quality stone made in Spain. Installation botched in the USA. MKD: the pinnacle of demolition.

Entitlement: falsely believing that customers are going to pay you just because you send an invoice — no matter how crappy your work is, how lacking your communication, and how poorly you run a business.

I love paying people for their hard work. When they actually earn it.

If a doctor treated their patients the way MKD treats their customers, they would be imprisoned, de-licensed, and shamed. In the world of Costco “special vendors” though, it’s apparently another job well done. That’s the high bar of Costco quality.

If you can’t build it, threaten your customer with legal action, collections, and worst of all — revocation of their Costco cards. Good thing I already shredded mine. That’s the MKD way.

If you paid your lawyers half of what you pay your human wrecking balls, “project manager” harassers, and “credit managers,” you would spare yourself a lot of unnecessary and avoidable problems. Good legal advice pays for itself.

Posted on by omarmetwally

Internal Medicine: Distilled

By Omar Nabil Metwally, MD
Internal Medicine Physician
First published 30 August 2026 · Revised and expanded with references

One of the most important classes that I attended as a Clinical Informatics Fellow at UCSF was a course on clinical research. This reflection surprises me in hindsight because I long associated “Clinical Informatics”, which was then a new medical specialty (I was in UCSF’s second class and their third Clinical Informatics Fellow), with the intersection of technology and patient care — a niche for technologically-affine physicians capable of transforming healthcare, if only (so the reasoning) they connected with the right decision makers, got on the right Teams calls, and joined the most elite mailing lists. I was not expecting to sit down almost 10 years later to write a blog post about what I then considered the driest of subjects: biostatistics.

In retrospect, I had a lot to learn, and I could have learned those valuable lessons with a more open and receptive mindset. I consider Professor Pletcher’s course significant in two regards. First, it gave me an opportunity to think deeply about the tests that doctors (especially non-surgeon physicians) routinely order on behalf of their patients and are expected to interpret and act upon correctly. Second, it planted the seed for the realization, many years after my time at Parnassus, that the specialty of Internal Medicine boils down to one concept: a priori likelihood.

There are two types of doctors that take care of people: physicians and surgeons. Physicians — doctors like internists and pediatricians — do a bulk of their work in the cognitive realm, which often takes the form of making a short-list of diagnoses and honing in possibilities (in medical jargon, this is called making a differential diagnosis). This is in contrast to surgeons, whose work tends to be more operative in a hands-on, physical sense than a physician. A physician who does not understand the tests they are ordering, the diagnostic consequences of their choice of test, and how to interpret the results, is like a surgeon without the physical skills necessary to perform a particular operation. I’m deliberately over-simplifying to make the point that despite the fact that test ordering and interpretation has traditionally been a core competency of physicians in general, I encounter an alarming number of physicians, new and experienced alike, who lack the skills to understand what they’re ordering (or not ordering) and how to correctly interpret positive and negative results. Equally alarming, and I suspect related, is organizational policies that narrowly prescribe diagnostic protocols in order to move a patient from point A to point B on the healthcare labyrinth — in the process, stripping physicians of what little autonomy they still have to exercise their clinical judgement.

The objective of this writing is to capture that lesson for any doctor who will ever order (or decide not to order) a test and be expected to interpret the result — if they are lucky to even have the choice.

The order that sounds correct

A middle-aged man presents with months of progressive hip and buttock pain. The pain is worst in the first hours after waking and after prolonged sitting. It wakes him at night. He has a years-long history of intermittent low back pain, a personal history of eosinophilic esophagitis, and a family history of autoimmune disease. Plain films show mild bilateral hip osteoarthritis — premature for his age. He asks for a rheumatology referral.

A reasonable-sounding plan: order an ANA and rheumatoid factor first. If negative, hold the referral. If positive, refer.

That plan has the shape of good medicine — screen, then escalate. It is also, for this presentation, close to backwards. Two errors are stacked inside it, and the second one is the more instructive.

Error one: the tests cannot see the disease

The clinical question here is axial spondyloarthritis. AxSpA is a seronegative spondyloarthropathy — and “seronegative” is not decoration. RF is expected to be negative. ANA has no association with the disease and appears nowhere in the ASAS classification criteria [1]. No result either test returns can move the probability of axSpA in either direction.

So the proposed gate was built from tests that cannot detect the condition being gated. A negative result would have been recorded as reassurance while carrying zero information about the actual question.

Error two: predictive value belongs to the patient, not the test

Here is the concept the wards tend to erode: sensitivity and specificity are properties of the assay. Positive and negative predictive value are properties of the encounter. The same ANA, on the same analyzer, means something entirely different depending on who is in the chair.

Do the arithmetic once and it inoculates you.

Worked example: the ANA in this patient

ANA is positive in roughly 20–30% of healthy adults at a 1:40 titer, and 10–15% at 1:80 [2]. Our patient has monoarticular hip pain with a mechanical mechanism, an axial pain pattern, and no features of connective tissue disease. Be generous and set the pretest probability of an ANA-associated disease at 0.5% — 1 in 200.

Per 1,000 similar patients Test positive Test negative
Disease present (5) 5 0
Disease absent (995) ~120 ~875
Total ~125 ~875
Assuming ~95% sensitivity and ~88% specificity at a 1:80 cutoff [3].

PPV = 5 / 125 = 4%. Twenty-four out of every twenty-five positives are false. A positive ANA in this patient is not a signal — it is noise wearing the costume of data.

And the costume is expensive. A positive ANA in the chart is never inert: it cascades to an ENA panel, a dsDNA, a “possible early connective tissue disease” note, a referral placed for the wrong reason, a patient reading about lupus at 2 a.m., and a label copied forward through every future chart review. The harm of a low-value test is rarely the test. It is the machinery the result switches on.

Worked example: the test that actually earns its place

Now run HLA-B27 through the same patient. Sensitivity is roughly 85% for axSpA — best established for radiographic disease, somewhat lower for non-radiographic axSpA and in non-European ancestries — with specificity around 90%, capped by a background allele frequency of roughly 6–8% in US populations of European descent (and higher still in Scandinavia) [4]. That yields LR+ ≈ 9 and LR− ≈ 0.15.

Given the inflammatory pain pattern, morning predominance, hip involvement, male sex, and family history, a pretest probability of 35% is defensible (pretest odds ≈ 0.54).

  • Positive: 0.54 × 9 = posterior odds 4.9 → ~83% post-test probability. Decision-changing.
  • Negative: 0.54 × 0.15 = posterior odds 0.08 → ~7% post-test probability. Also decision-changing, in the opposite direction.

That is the signature of a test worth ordering: both results move you substantially, from an intermediate starting point. Note the dependency, though — run that same B27 on unselected back pain with a 2% pretest probability and the PPV falls under 20%. The likelihood ratio is a property of the assay; the usefulness is a property of your clinical reasoning.

And the tests that are neither: CRP and ESR

Worth naming because their prominence in “inflammatory workups” oversells them. CRP is elevated in only 40–50% of axSpA — a normal value carries a likelihood ratio near 1 and excludes essentially nothing. Their value here is prognostic (elevated CRP is one of the strongest predictors of radiographic progression, alongside baseline syndesmophytes and smoking [5]), as a baseline for treatment monitoring and ASDAS scoring, and for flagging infection. Diagnostically, they are close to inert. Order them knowing which job they are doing.

A worked example everyone lived through: the COVID home test

During the pandemic the federal government mailed free rapid antigen tests to any household that asked — well over a billion tests moved through federal programs before distribution wound down and was finally suspended in March 2025 [6]. Today the same tests sit on pharmacy shelves at $10–20 a box, and most people with a cough don’t bother. That shift is the thesis of this essay playing out at national scale — though the arithmetic contains a surprise worth sitting with.

At the Omicron peak, roughly half of symptomatic adults with acute respiratory symptoms actually had COVID: in CDC’s outpatient surveillance network, 56% of symptomatic adults tested positive during Omicron predominance [7]. Rapid antigen tests in symptomatic people carry a pooled sensitivity of about 73% and a specificity of about 99.6% [8]. Per 1,000 symptomatic people at 50% prevalence: 365 true positives against 2 false ones — a positive predictive value near 99.5%. The test was superb, and it was superb because of who was taking it.

Today, the same symptoms in the same person carry perhaps a 10% probability of COVID in a typical week — the rest is rhinovirus, RSV, influenza, and everything else — and closer to 3% in a deep trough between waves. Same assay, same operating characteristics. At 10% prevalence: 73 true positives against about 4 false ones — PPV around 95%. At 3%: PPV around 85%.

Here is where the intuition usually goes wrong, and it is the most instructive moment in this essay. The PPV fell — but nowhere near as far as it did for the ANA in our patient, whose PPV was 4% at low pretest probability. Why the difference? Specificity. The antigen test generates false positives at a rate of about 0.4%; the ANA at a 1:80 cutoff generates them at about 12%. When prevalence drops, a test with a fraction-of-a-percent false-positive rate degrades gracefully, and a test with a double-digit false-positive rate falls off a cliff. Pretest probability sets your ceiling; specificity determines how fast you fall from it. A positive home COVID test today is still probably real. A positive ANA in a patient without connective-tissue-disease features almost never is.

One more property worth internalizing: the sensitivity of a strategy is not the sensitivity of a test. A single antigen test on the first day of symptoms detects only about 60% of infections, but two tests taken 48 hours apart detect over 93% [9] — which is exactly why the FDA recommends repeat testing after a negative result [10]. Operating characteristics belong not just to the assay but to how you deploy it.

So why did universal home testing wind down? Partly for structural reasons that have nothing to do with epidemiology: the public health emergency ended in May 2023 and took the insurer free-test mandate with it, federal distribution stopped, and the tests now cost real money. But the clinical logic tracks the third question of this essay: will the result change what I do next? Under CDC’s unified respiratory-virus guidance, isolation is now symptom-based — stay home until improving and fever-free for 24 hours — regardless of which virus you have [11]. For a healthy, low-risk adult with mild symptoms, a positive test changes little about their own care.

And notice that the answer flips right back for the people in whom question three is still answered yes: anyone eligible for antiviral therapy, where a positive result starts a five-day treatment clock [12]; anyone about to sit down with an immunocompromised relative; healthcare workers and congregate settings, which the relaxed guidance explicitly does not cover. The newer over-the-counter combination flu/COVID tests sharpen the point further — in a high-risk patient, distinguishing influenza from COVID selects between two different antivirals. Same test, same prevalence, opposite recommendation — because the question being asked is different.

We ran a natural experiment on 300 million people, and the lesson was the one Professor Pletcher was teaching in a classroom on Parnassus: the test never changed. Who we gave it to, and what we planned to do with the answer, changed everything.

The three questions that replace the panel

The fix isn’t memorizing which panel goes with which complaint — panels are how we got here. It’s a habit, asked in order, before anything is ordered:

  1. What disease am I testing for? Named and specific, out loud. Not “inflammatory something.” If you can’t name the disease, you can’t choose the test — tests are only interpretable against a named hypothesis.
  2. What is my pretest probability — even crudely? “Under 5%, coin flip, or over 50%” is enough resolution to change behavior. The discipline is committing to a number before the result exists. A probability estimated afterward isn’t an estimate; it’s a rationalization.
  3. Will either result change what I do next? If positive changes nothing and negative changes nothing, the test’s only outputs are cost, noise, and cascade risk.

Run the case through them. Disease: axSpA. Pretest probability: intermediate. Will ANA/RF change the next step? No — the MRI and the referral were indicated regardless of serology. Question three deletes the ANA in about four seconds. It also reveals something sharper: the problem wasn’t only which tests formed the gate. There should have been no gate.

Why good physicians make this error

This is not stupidity. It is a systems failure with a cognitive assist, and you should recognize the ingredients, because they will be your working conditions:

  • Order sets are frozen decisions. Someone decided once that ANA + RF = “rheum labs,” and the EHR has been re-making that decision on autopilot ever since. Every checkbox panel is a colleague from the past overriding your present reasoning — sometimes correctly, and you won’t know which times unless you look.
  • Covering is medicine at low resolution. An unfamiliar chart, an intermediary, a message queue. Pattern-matching to “joint pain → rheum panel” is what cognition produces under those constraints. The antidote isn’t heroic effort; it’s cheap heuristics that survive low resolution — which is what the three questions are.
  • “Baseline” is a thought-terminating word. Nobody argues with a baseline. But a baseline is just a test whose pretest probability nobody bothered to state.

And the sequel matters. When this reasoning was raised — politely, in writing — the physician reviewed the chart and ordered the appropriate labs within two hours. That responsiveness is the trait to emulate. The initial error was ordinary; the rapid update was excellent medicine. If you take a villain from this story, you’ve misread it. The villain is the reflex, and every one of us has it.

The distillation

A test result is not information about the patient. It is information about the patient conditional on why you ordered it.

The test doesn’t know who you ordered it on. You do. The entire interpretive weight of every result you will ever receive rests on the probability you assigned — explicitly, or by default — before you clicked the order.

Assign it explicitly. Every time. Ten seconds, and it is the highest-yield ten seconds in diagnostic medicine.

References

  1. Rudwaleit M, van der Heijde D, Landewé R, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009;68(6):777–783.
  2. Tan EM, Feltkamp TE, Smolen JS, et al. Range of antinuclear antibodies in “healthy” individuals. Arthritis Rheum. 1997;40(9):1601–1611.
  3. Leuchten N, Hoyer A, Brinks R, et al. Performance of antinuclear antibodies for classifying systemic lupus erythematosus: a systematic literature review and meta-regression of diagnostic data. Arthritis Care Res (Hoboken). 2018;70(3):428–438.
  4. Reveille JD, Hirsch R, Dillon CF, Carroll MD, Weisman MH. The prevalence of HLA-B27 in the United States: data from the US National Health and Nutrition Examination Survey, 2009. Arthritis Rheum. 2012;64(5):1407–1411.
  5. Poddubnyy D, Rudwaleit M, Haibel H, et al. Rates and predictors of radiographic sacroiliitis progression over 2 years in patients with axial spondyloarthritis. Ann Rheum Dis. 2011;70(8):1369–1374.
  6. US Department of Health and Human Services. Federal at-home COVID-19 test distribution program (COVIDTests.gov), January 2022; distribution suspended March 2025.
  7. Kim SS, Chung JR, Talbot HK, et al. Effectiveness of two and three mRNA COVID-19 vaccine doses against Omicron- and Delta-related outpatient illness among adults, October 2021–February 2022. Influenza Other Respir Viruses. 2022;16(6):975–985.
  8. Dinnes J, Sharma P, Berhane S, et al. Rapid, point-of-care antigen tests for diagnosis of SARS-CoV-2 infection. Cochrane Database Syst Rev. 2025;CD013705.
  9. Soni A, Herbert C, Lin H, et al. Performance of rapid antigen tests to detect symptomatic and asymptomatic SARS-CoV-2 infection: a prospective cohort study. Ann Intern Med. 2023;176(7):975–982.
  10. US Food and Drug Administration. At-home COVID-19 antigen tests: take steps to reduce your risk of false negative results. FDA Safety Communication, August 2022.
  11. Centers for Disease Control and Prevention. Respiratory virus guidance. March 2024.
  12. US Food and Drug Administration. Nirmatrelvir-ritonavir (Paxlovid) prescribing information: treatment of mild-to-moderate COVID-19 in patients at high risk for progression, initiated within 5 days of symptom onset.

Clinical details are composite and deidentified. Test characteristics are approximate, vary by assay, cutoff, population, and timing, and are cited to their principal sources above — the arithmetic is illustrative, and the habit is the point.