The decision to split those services took three months.

Undoing it will take nine months.

Nobody wrote that ratio in the Architecture Decision Record. Nobody calculated the asymmetry before committing. The decision was made based on the cost of building. The cost of unbuilding, three times larger, was never priced. It rarely is.

Every architectural decision sits on a spectrum. Two-way doors can be reversed in a sprint. Narrow doors feel reversible but create structural dependencies that make reversal expensive. One-way doors are effectively permanent within any realistic planning horizon.

The classification error that produces nine-month reversal projects is treating narrow or one-way door decisions like two-way doors. The technology is familiar. The pattern is well understood. The permanence is invisible until the day you need to go back and discover you cannot.

None of the Three Filters, the 2 AM Test, the Half-Rule, Primary Path First, asks about reversibility. The Filters evaluate whether the architecture is operable, scoped, and organized. Only the fourth filter, the Reversibility Test, asks whether the level of commitment matches the level of certainty.

Reversibility is the most underpriced quality in software. Every one-way door looks like a corridor until you need to go back. The option to course-correct has real economic value. Every irreversible decision forfeits it. The organizations that survive the accumulation of one-way doors are the ones that priced reversibility before the door closed.

The decision that costs one sprint to make can cost three quarters to reverse. Which decisions in your current architecture would you be willing to remake with full knowledge of the cost of reversing them?

The Simplicity-First Philosophy

The Architecture of Regret: Why Reversibility Is the Most Underpriced Quality in Software

The sprint retrospective runs long. It has been running long for three months…

Read more

6 months ago · 1 like · Chris "Woody" Woodruff

The conference talk was excellent. Fourteen microservices, event-driven choreography, a custom service mesh and a polyglot persistence layer with four database engines. The architect who built it received a standing ovation and an offer for a senior staff position at a bigger company within six weeks.

The system the talk described had been in production for eleven months. It served 4,000 daily active users. A modular monolith on PostgreSQL would have served them with one-tenth of the operational overhead.

Nobody asked.

This is the open secret of the modern engineering market. Complexity is the currency of technical prestige. Sophisticated systems earn conference talks. Simple systems do not. Senior engineers who advocate for the modular monolith have less career capital than those who migrate to microservices, even when the monolith is the correct decision for the business.

The labor market values complex experience. The next employer pays the salary uplift for complex architecture. The architect who builds simple systems competes for the same roles against architects whose resumes list more sophisticated stacks. The market consistently rewards the wrong behavior at scale.

Three actors profit from this equilibrium. The architects who build complex systems and ride the resume to the next role. The cloud providers and tooling vendors whose revenue scales with the complexity. The conference and training industry, whose entire business model assumes the audience needs to learn the next sophisticated pattern.

The actor who pays is the organization. The bill arrives over the years, in cloud invoices, operational overhead, and the engineering capacity consumed by maintaining systems that did not need to be complex in the first place.

Read more at the link below.

The Simplicity-First Philosophy

The Status Architecture: Why Complexity Is the Currency of Technical Prestige and Who Pays the Bill

Two performance reviews are happening in the same engineering organization on the same day…

Read more

6 months ago · Chris "Woody" Woodruff

That is the part that keeps me up at night. Not that the disease is hard to treat. It is that we are catching it so late.

This week on The Heart of Innovation, Dr. John Phillips and I sat down with a research team from UC San Diego that is working to change that: vascular surgeon Dr. Elsie Ross, cardiologist Dr. Mattheus Ramsis, and engineering PhD student Ava Faccetti. What they are building together started with a cup of black coffee and a question that nobody had thought to ask before.

Dr. Ross had been in AI since 2013, long before it was a buzzword in medicine. She was thinking about PAD patients showing up too late, primary care doctors not checking pulses, people going years without a diagnosis and then landing in surgery. Dr. Ramsis had been working with PPG signals since a fellowship at UCSF, where he helped co-develop the AFib detection algorithm that Samsung uses in their smartwatch today. When they both ended up at UCSD as medical directors of informatics, Dr. Ramsis pitched his work at a meeting, and Dr. Ross was in the audience. She knocked on his door the next day and said they should talk.

Over coffee, she told him about PAD and the physiology behind it. He told her about PPG signals. And then somebody mentioned that a PPG signal is captured at the same time a patient gets an ankle-brachial index test. They looked at each other and both had the same thought at the same moment: there is probably something here.

PPG stands for photoplethysmography, which is why everyone on the show quickly agreed to just call it PPG. It is the same light-reflection technology your smartwatch uses to track your heart rate. You can capture it from any vascular bed, a finger, a wrist, a toe. What Dr. Ross realized was that if you put the sensor at the toe, you are reading the signal right where PAD shows up first. Arteries narrow from the feet up. The toe is the canary.

The team pulled thousands of signals from the vascular lab, with help from medical student collaborator Mustafa who physically extracted them from the records. Ava took those signals and did something that Gemini will describe as AI and that Ava herself would push back on slightly. They did not just feed the data into a model and hope for the best. They sat in meetings with Dr. Ross and looked at signals side by side, some from patients with PAD and some without, and asked her to tell them which was which and why. They were trying to translate physiology into something a computer could reason about. That is a different thing than a black box algorithm spitting out a prediction with no explanation behind it.

They validated the model against the ABI, the ankle-brachial index, which is the clinical gold standard for PAD diagnosis. And the results were strong enough that about nine or ten months ago, sitting in a meeting, they looked at what they had found and said: yeah, this is going to work.

The vision from here is not another expensive machine bolted to the floor of a specialty clinic. It is a consumer device. Something you can use at home, or at CVS, or at your fire department, the same way you check a blood pressure or take a temperature. Not a diagnosis, but an indication, something that says you should probably go see someone about this, before tissue is dying and surgeons are out of options.

Dr. John made the point on air that this is how medicine has to move. We have spent decades building remarkable tools that live inside the walls of specialty practices and academic medical centers. The patients who need them most are the ones least likely to walk through those doors. Rural patients. Patients with no primary care. Asymptomatic patients who feel fine right up until they do not.

An ABI requires you to show up, lie down, have a cuff put on your arm and your leg, and have someone calculate the ratio. That is a real barrier for a lot of people. A four-second toe signal on a phone is not.

I have covered healthcare innovation for a long time and I have sat across from a lot of researchers. What I noticed about this team is that none of them started with the technology and worked backward to find a problem to solve. Dr. Ross started with patients who were losing limbs and worked forward to find a tool that could reach them earlier. It’s important to always start with the patient. It is the difference between a product and a mission.

They are still in the validation phase. There is more work to do. But the core algorithm is built, the foundational paper is complete, and the goal is an FDA-approved screening tool that puts some version of a vascular lab reading in the hands of the people who need it most.

If you want to hear the full conversation, including how Dr. Ramsis accidentally missed the first meeting with Ava’s lab director and it somehow still worked out, click the video above or find us on YouTube at youtube.com/@TheWayToMyHeart or catch us live on AM 1220 KDOW every Saturday morning.

And if you or someone you know has leg pain, wounds that do not heal, or feet that are cold or numb, please do not wait for a device. Call our leg saver hotline at 1-833-PAD-LEGS or visit padhelp.org. The current standard of care can still save a limb if you catch it in time. That is what we are here for.

More on the research:

DOI: https://doi.org/10.1038/s41746-026-02655-w

Vern and I go back to the Konocti Harbor Quarterback Shootout, a celebrity golf tournament at Konocti Harbor Resort up in Lake County. He was at KRON 4 at the time, deep into the segment that made him famous around here, “Mr. Involvement,” where his producers would find ways to throw him into whatever sport he was covering. Not cover it. Do it. He got tackled by NFL players, pinned on wrestling mats. So when the shootout wanted water sports coverage and somebody said, hey, there is a fellow Bay Area sports anchor who performs as a professional show skier at Six Flags Marine World in Vallejo on weekends, the decision made itself. They brought me in to show Vern how it worked on a swivel ski.

He held up fine. What he did not know was how easy I went on him. On weekends I was the cherry on top of a three-tier human pyramid on water, holding the American flag in a pink skirt, skiing around the lake. I could have put him in that pyramid. We still have the video. Watch the episode if you want to see what the early career looked like before the microphone.

That is how we met. He became a mentor. Years later we both ended up on a healthcare innovation radio show, and the fact that it is not as strange as it sounds is exactly what this episode is about.

When the Body Sends a Bill

Vern turned 64 this year. He looks like he is in his 40s and he will tell you so himself, but here is the thing he also told us on air: when you are young, you feel like a tank. Nothing touches you. The late nights, the bad habits, whatever you need to get through the grind of a 41-year career. And then somewhere in your 50s, the body sends a bill. His came as a Type 2 diabetes diagnosis. Pre-diabetes first, then Type 1, now Type 2, and every single day is about working the A1C number down through exercise, diet, and weight management. He wants to be around for grandkids someday. He wants 20 more years. Those are his words, not mine.

That lands on a healthcare innovation show because Type 2 diabetes is not separate from what we cover. It is a vascular disease. It damages arteries. It is one of the primary drivers of peripheral artery disease, of critical limb threatening ischemia, of the exact conditions our leg saver hotline exists for. The people who call us often did not know how interconnected it all was until something went wrong. Vern knowing it, managing it, talking about it publicly at 64, that is the message.

Which brings us to June 8th. Every year, Vern hosts the Vern Glenn Invitational, a celebrity charity golf tournament in Marin County that benefits local Marin charities. The lineup reads like a flashback reel of Bay Area sports history. Lorenzo Neal, 16-year NFL veteran and Vern’s own guest analyst during football season, whose block on the Music City Miracle kickoff is one of the most important plays in playoff history. Bill Cartwright, longtime Chicago Bull. Toy Cook, 49er Super Bowl champion. JT, who won the very first VGI. Brandy Chastain won last year’s celebrity putting contest, only woman in the field, took home a gift certificate to Omaha Steaks, and is missing this one because June 8th is her wedding anniversary and her son’s birthday. Nobody is fighting her on that.

None of these people are paid to be there. Vern told us that plainly. They get treated well, championship course, plated dinner, but they volunteer their time. And some of them keep coming back because, as Vern put it, time has passed them by and people have forgotten. Being asked still means something. He wants to hear every story, even the ones he has heard 20 times over. You could see it when he talked about interviewing Hank Aaron at Candlestick Park on a live shot, calm and composed on camera, absolutely screaming on the inside because he was talking to the home run king. He has been in this business for 41 years and he still screams on the inside. That is why there are six Emmys.

What Six Emmys Actually Takes

Dr. John wanted to know how you actually get an Emmy, and the answer is worth knowing. In the Northern California region, you compile your best work, up to 10 or 15 minutes depending on category, and submit it to be judged by peers in markets that have no idea who you are. Blind scoring on a seven to ten point scale. Not every category produces a winner. If nobody scores high enough, the award simply does not go out that year. Vern was nominated five times before he won. His mother refused to attend any of the ceremonies until he actually took one home. When he finally did, he was the only person nominated in his category. His category is a solo craft award, one person, no ensemble, judged on nothing but what you did in front of a camera. He has won it six times.

He just re-signed at KPIX. He said he has a number in mind, a point where he will know it is time, but he is not there yet. Dr. John made the point on air that staying engaged, working, learning, doing things that require your brain to stay sharp, is itself a form of disease prevention. The research on cognitive decline backs that up. Retiring with nothing to do is not rest. It is a risk. Vern loves what he does. That still matters.

Golf is part of it too. He had stepped away from playing for a while, and the tournament pulled him back. Walking 18 holes is three to five miles. Gary Player, who Vern quoted on air, said happiness is a long walk with a putter, and Player is in his late 80s still competing. For someone managing Type 2 diabetes, that is not a hobby. That is medicine. And watching former 49ers and NBA veterans stay out on the course in their 60s and 70s is the kind of modeling that no PSA ever quite achieves, because it is just people you respect doing the work in front of you.

Back to the key lime pie, because it is the best way to close this. May 2020, everybody locked down, my dad’s birthday coming up and he had one request, a key lime pie from a place that was closed. I mentioned it to Vern. He said bring your dad over. We will sit outside six feet apart and I will make him one. He did not know my dad. He just offered. My dad has not stopped talking about it since, and this year, for his birthday, he had one request: Vern Glenn and another key lime pie. He got both.

That is the whole person. Six Emmys, 41 years, Hall of Fame. And he still makes the pie.

The Vern Glenn Invitational is Monday, June 8th. Registration and details at vernglenninvitational.net. Arrive around 9am, meet the athletes, have breakfast. All proceeds go to local Marin County charities. And if you happen to see someone near the first tee with a blood pressure cuff, that is us. Purely voluntary. The shoes can stay on.

The Heart of Innovation airs every Saturday morning on AM 1220 KDOW. Watch the full episode on YouTube at youtube.com/@thewaytomyheart or click on the video above.

Most of the technology world never knew that Phil McKinney has been managing a genetic heart condition since he was 17 years old. It runs in his family. His father nearly died from it at a time when the medical community barely understood it, and it can kill a young, healthy person mid-game with no warning whatsoever.

A close friend of mine, Justin, who ran Patient Pro Marketing in the vascular world, died from it not long ago. He had no idea he had it, and neither did anyone in his family. That story is far more common than Phil McKinney’s, which is exactly why McKinney’s is worth telling.

The condition is hypertrophic cardiomyopathy, or HCM, a genetic mutation that causes the heart’s left ventricle, the main pumping chamber, to thicken abnormally. About one in 500 people carry it, most without any idea. As that wall thickens, it can block blood from leaving the heart through the aorta, generate lethal electrical rhythms, and cause sudden cardiac arrest.

McKinney and his father carry the apical variant, where the thickening concentrates at the very tip of the heart rather than the upper wall. In the U.S. it accounts for roughly three to ten percent of HCM cases depending on the population studied. Both forms can carry a risk of dangerous arrhythmias and sudden cardiac death. The difference is where the thickening occurs and how it’s found. Standard HCM can sometimes show up on a regular echocardiogram. Apical HCM frequently doesn’t, and cardiac MRI is often the only way to see it, which is part of why it goes undiagnosed for so long.

Dr. John Phillips, my co-host on The Heart of Innovation and an interventional cardiologist, described how this plays out: when a soccer player drops on the pitch or a football player collapses mid-game, HCM is frequently the culprit. “It can affect a young, healthy person and cause sudden death,” he said. Most of the time, the person had no idea anything was wrong.

McKinney’s father found out in 1975 or 1976 through a routine physical required for an adult Boy Scout volunteer position. Their family physician in Chicago caught a faint murmur and sent him to the University of Chicago, where one of the few cardiologists working in this area at the time confirmed the diagnosis. Two years later, the elder McKinney went in for open-heart surgery to thin the thickened wall. He was only the seventh person in the world to have the procedure. Dozens of physicians crowded the OR, and the family signed releases so the surgery could be filmed and shared with cardiologists across the country.

Phil McKinney was 17 and in the waiting room that November. He had just started dating Michelle that September, the same month the University of Chicago brought in his father’s male relatives for early genetic testing and Phil received his own diagnosis. They had met three years earlier through the Boy Scouts Explorer program. When they started dating, she asked how close he was to his Eagle Scout. Five merit badges, he told her, three weeks, probably not enough time. She told him she didn’t date non-Eagles. He finished five merit badges in three weeks and earned his Eagle with 11 hours to spare before his 18th birthday.

His soccer career ended that same fall.

McKinney has lived with this condition for nearly 50 years, and what he describes most is that he feels nothing. Today his heart throws ventricular tachycardia and premature ventricular contractions in patterns that alarm hospital monitoring teams on sight, 20, 25, 30 consecutive beats of VTAC. Staff always ask him the same question: don’t you feel it?

“I don’t feel the arrhythmias,” he said. “I don’t think my heart rhythm has ever been normal. I don’t know what normal feels like for everybody else.”

That answer explains why this condition kills people who had no warning. When you have never had a normal baseline, nothing feels out of the ordinary. The disease progresses and the person has no idea, which is how a seemingly healthy athlete ends up face down on a court.

Stanford became central to McKinney’s care when he joined HP and moved to the Bay Area, where his uncle already lived in Vallejo and his brother eventually settled. Dr. Euan Ashley, who founded Stanford’s Center for Inherited Cardiovascular Disease and now chairs the Department of Medicine there, brought the living male members of the family together for testing.

That monitoring showed medications alone weren’t enough. McKinney became a test case for early non-invasive cardiac monitoring before eventually receiving an implantable cardioverter-defibrillator, an ICD that watches his heart rhythm continuously and delivers a shock if a lethal rhythm takes hold. He’s now on his third device, with battery swaps every seven to eight years. It has never fired.

His father’s device did, more than once, and McKinney witnessed some of those episodes. His father grew up in Kentucky and described the sensation as being kicked in the chest by a horse, a comparison he knew firsthand. When McKinney’s own device was implanted, the technician asked whether he wanted an audio tone to count down the seconds before a potential shock. His answer was no. “I don’t want the stress of the beep beep beep counting down. No thank you.”

Douglas Salisbury, who leads our PAD Warrior Task Force and also has apical HCM, knows what a firing device feels like. Three days after his myectomy, his device went off three times in ten minutes. “I have never experienced anything like that in my life,” he said.

McKinney also carried coronary artery blockages from his mother’s side. In February 2023, his wife Michelle, a neonatal intensive care nurse who spent 25 years in that specialty and earned her master’s in nursing from the University of Evansville, dragged him to Mayo Clinic for his annual workup, as she always does. His standard echos came back flagged, and the clinical team told him to stay.

He ended up in open-heart surgery. The plan was a quadruple bypass, but surgeons could only complete three once they were inside because scar tissue and buildup around the heart blocked access to some of the blockages entirely. While they had him open, they also performed a MAZE procedure, surgically rewiring the heart’s electrical pathways to address the atrial fibrillation he had been fighting for years. McKinney had been cardioverted roughly 35 times in his life, on a cycle of needing the outpatient procedure every six weeks because his heart would never convert back on its own. Since February 2023, he has had zero episodes of AFib.

All three of McKinney’s children have been tested. His oldest daughter carries the mutation but has not developed the disease. When she gave birth to McKinney’s first grandchild 13 years ago, Stanford sent two cardiologists to observe the delivery at the other hospital to monitor for any cardiac effects from labor.

The family had secured life insurance for all three kids before any genetic testing happened, knowing what a diagnosis could mean for coverage. McKinney himself has been uninsurable for individual life coverage since he was 17, relying entirely on employer group policies through his career at HP and CableLabs. A diagnosis follows you through every insurance application you’ll ever fill out.

McKinney’s message to anyone with family history of cardiac events, and especially to parents of young athletes, is to push for an echocardiogram and fight with the insurance company if necessary. A routine youth sports physical won’t catch a structural abnormality. A five-minute echo very often will. If there’s cardiac history in the family, ask about genetic testing, because identifying the mutation gives the next generation a chance at the same outcome McKinney and his brother have had.

“Be an advocate for yourself,” he said. “Find good care. With early diagnosis and good medical care, you can have a great, normal life.”

McKinney is 65. His brother is approaching 70. Their father made it to 68 before the condition took him. A family physician heard a murmur at a Boy Scout physical and sent a man to the right doctor. That one referral changed everything for three generations of McKinneys.

Justin never got that far. He never knew there was anything to find. Get checked.

If you have questions about this story, you can call the Global PAD Association’s Leg Saver Hotline at 1-833-PAD-LEGS.

The CTO announced the consolidation in April. Fourteen microservices would become four. Executive sponsorship. Dedicated team. Hard deadline.

Eighteen months later: eleven services. Three more than the target. More coordination meetings than before the program began. Two of the four consolidated services had already been split again.

The CTO called it a partial success. Nobody said out loud what had actually happened.

The architecture was simplified. The org chart was not. So the org rebuilt what it needed.

This is the half of Conway’s Law nobody finishes. Everyone cites the forward direction: organizations produce systems that mirror their communication structures. Almost nobody discusses the reverse. Restructure the system without restructuring the teams, and the teams will rebuild the system they are organized to produce.

The eighteen-month figure is not arbitrary. It tracks two engineering tenure cycles. 69% of software developers have tenure of less than 2 years. Within eighteen months, the engineers who understand the consolidation will be gone. Their successors follow the communication patterns they inherited, not the diagram. The patterns win.

This is Conway’s Revenge: the org chart keeps writing code whether anyone is watching or not.

The full essay covers what simplification programs miss, why the reversion is so consistent, and what the Inverse Conway Maneuver actually requires from a CTO who wants the simplification to hold. It also adds a missing line item to the Total Cost of Architecture: the org design cost embedded in every service boundary.

The service boundary in your architecture diagram is a headcount requirement in your org chart. The two documents describe the same thing.

Read it on Simplicity-First Philosophy.

The Simplicity-First Philosophy

Conway's Revenge

The CTO announced the consolidation program on a Monday in April. Fourteen microservices would become four. The architecture diagram, which had required a 4K monitor to read without squinting, would become something a new engineer could understand in an afternoon. There was executive sponsorship. There was a dedicated team. There was a hard deadline…

Read more

7 months ago · 1 comment · Chris "Woody" Woodruff

Your architecture review board was created to prevent complexity. It is producing more of it.

That is the argument I make in this week’s essay over at Simplicity-First Philosophy, and the evidence is not subtle.

Walk into any ARB meeting. Listen to the questions. “What about international expansion?” “What about ten times the load?” “What if we need to swap databases later?” Every question is reasonable. Every question adds an edge case. Every edge case adds a service, a layer, a contract.

Nobody gets criticized for raising a concern. Everyone gets criticized for missing one.

So the meeting reaches its quiet equilibrium: everybody adds complexity, nobody removes it. The board signs off feeling diligent. The architect leaves with three new requirements. The system gets heavier. Multiply that by every quarterly review for the past five years, and you get the architecture you have.

And the meeting is only the visible part. The problem is not the people in the room. The problem is the rules of the game.

The essay walks through three reasons review boards cannot fix what they were built to fix:

Reviewers share the same incentive structure as the reviewed. Asking architects to evaluate whether an architecture is over-engineered is asking them to question the value of their own resumes.

The simpler alternative is invisible. The twelve microservices got built. The modular monolith did not. You cannot defend a system that was never given a chance to exist.

The review process measures documentation, not design. Forty-seven slides and a risk matrix score higher than a one-page ADR that clarifies the actual decision. Completeness is legible. Quality of judgment is not.

The full essay covers what to put in place of ARB theater: lighter governance, ADRs with breakeven analysis, and a single rule that changes the whole conversation.

Kill the bloat. Start with the meeting that creates it.

Read it here:

The Simplicity-First Philosophy

The Governance Trap: How Architecture Review Boards Manufacture the Complexity They Were Built to Prevent

The meeting starts at 10 a.m. on a Tuesday. Seven people sit around a table. The architect at the front of the room has spent three weeks building the proposal. Forty slides. Service diagrams with fifteen labeled boxes. A sequence diagram that took two days to draw. An event schema with six message types. A monitoring plan referencing four separate obse…

Read more

7 months ago · Chris "Woody" Woodruff

Don’t focus on facility name or Google reviews.

What you want to know is whether that vascular doctor has the practical skill set to take a wire and balloon all the way into the smallest vessels in the foot, when it’s medically appropriate, to restore blood flow and heal a wound.

Ask whether they have surgical options available at their clinic or through a direct referral if intervention isn’t enough.

The older doctor may have more experience. The younger doctor may be quicker to adopt newer techniques. What actually matters is whether they’ve worked below the knee and ankle, whether they’ve gone retrograde (coming up from the foot, calf, or behind the knee) when the anatomy called for it. And what surgical options are also available if wires and balloons aren’t enough.

Ask those questions directly.

The answer tells you more than any credential on the wall.

But skill set is only part of what you’re looking for. The other part is what happened later that same Friday night, after I got off the phone with that daughter.

I reached out to three vascular specialists I work closely with, Dr. Eric Secemski, Dr. Anahita Dua, and Dr. Matthew Menard. All three were in London at another prestigious conference called Charing Cross. It was 10:30 at night there. Dr. Menard had gone on to enjoy a couple of days in Copenhagen. I’m fairly certain I woke him up twice. All three responded. But Dr. Menard was first to respond and facilitated emergency room care for this woman, talked to his team, put his name down as supervising physician, requested all the appropriate tests, and committed to taking care of her personally on Monday. Dr. Dua and Dr. Secemski were ready to do the same.

On the show, Dr. Phillips quoted Adam Smith’s The Theory of Moral Sentiments: “The wise and virtuous man is at all times willing that his own private interests should be yielded to the public interest.” Three doctors, in the middle of the night, overseas, on their own time. That’s what it looks like.

And that kind of selflessness isn’t limited to legs.

The same spirit shows up when a heart stops, and sometimes the line between life and death is a forgotten laptop.

We aired a local TV news story on the show about a reunion between a man named Mark Lamont and the team at Riverside Methodist Hospital who brought him back to life last December. The reunion was coordinated by Abiomed, the company behind the Impella heart pump. Mark came inside from shoveling snow, felt chest pain, and his wife and son called 911. By the time EMS arrived, he was gone. The defibrillator was used on him forty times before his heart held.

Dr. Phillips was on call that day. The ER called to give him a heads-up that they had a heart attack patient coming in, which is standard. What’s also standard is that the interventional cardiologist waits for a follow-up call once the patient is stable and ready. Dr. Phillips was already on his way back to the hospital anyway to pick up a forgotten laptop. When he arrived, instead of going to his office to wait for that second call, he went straight down to the ER on his own. Nobody asked him to. He just went. What he found was a man being kept alive by a machine, a team that had run out of options, and an ER physician who told him there was nothing left to do. Dr. Phillips had to decide whether to call it.

“I could have just said, we’re done,” he told us. “That is on me. I would have put the nail, truly the nail, in his coffin.”

He didn’t call it. Mark Lamont survived, turned 69 in January, and is going to come on our show. A forgotten laptop put Dr. Phillips in the building. A gut feeling sent him down that hallway instead of to his office. “I call it serendipity,” he said. But serendipity only works if you show up.

Dr. Phillips also pointed out that Mark’s own habits played a role in making his body amenable to reboot. His body was fit enough to survive what forty shocks and an emergency intervention demand. “If he would have been sedentary, I mean, the guy was shoveling snow for crying out loud, he probably would not have survived,” he said. Exercise doesn’t guarantee anything. But it can be the difference between a body that has something left to fight with and one that doesn’t. And even when you do everything right, there are no guarantees. You can exercise, see your doctor regularly, get checked out, and still have no idea what’s quietly building.

I know that personally. On the flight home from Italy, I landed to a text from a friend telling me that Patrick Muldoon had died.

Most people know Patrick from Melrose Place, Days of Our Lives, Starship Troopers, and the Hallmark movies he had been making right up until the end.

I met him years ago when I hosted the red carpet for Star Wars: Revenge of the Sith.

A lot of the celebrities didn’t want to spend time with the public crowd, so a handful of them drifted upstairs where I was setting up for my TV broadcast. Patrick was one of them, and we just ended up talking for a while. Later, I did a story on him for Forbes about actors moving into music. He had a band called Sleeping Masses.

((Check out one of their songs I used for a KRON4 news segment on a new pastime in Silicon Valley, Snowkiting below))

I went down to his studio in LA, no air conditioning, baking hot, had to run the camera myself because my photographer couldn’t make it, and he was a complete sport about the whole thing. Afterward he took me to In-N-Out Burger for my first double-double. That was Patrick.

He was 57.

His girlfriend found him on the floor outside the shower. He was already gone. The most likely cause is a heart attack, possibly a blood clot, though no autopsy results have been made public so we don’t know with certainty. Dr. Phillips noted on the show that there are other possibilities too, a ruptured aneurysm, an aortic dissection. My own mother died of an aortic dissection that was written down as a heart attack. Without an autopsy, sometimes you never get a clear answer. What is certain is that whatever took Patrick moved faster than anyone could have intervened. These events can happen that way, silently, without warning, in someone who by all appearances had no reason to be at risk.

To Patrick’s family, his girlfriend, his best friend Karen McCullough, and his close friend Denise Richards, I am so sorry. He was a genuinely good person, and the tabloid headlines going after his past are not the story. The story is that he was kind, he was talented, and he was 57.

In honor of Patrick: Get your heart checked. Exercise. Pay attention. And if you’re dealing with a vascular condition and a doctor tells you nothing can be done, call us at the Global PAD Association on our Leg Saver Hotline at 1-833-PAD-LEGS before you accept that answer. Because as this episode showed, sometimes everything is possible. And sometimes the only thing standing between a patient and a lost limb or a lost life is a doctor willing to walk down a hallway.

But what if it didn’t have to be?

This week on The Heart of Innovation, we featured Dr. Chris Bruce, part of a research collaboration between the NIH and Emory University that just performed something that has never been done in human history:

A fully catheter-based coronary bypass, completed without opening the chest, on a beating heart, through a tiny puncture in the groin.

They are calling it VECTOR.

Joining us as co-host was Dr. James Joye, an interventional cardiologist who invented a minimally invasive catheter-based bypass technique for the leg arteries, now distributed by Endologix, and who has spent decades thinking about how to bring that same philosophy to the heart.

When I asked Dr. Bruce whether VECTOR signals the beginning of the end for the Zipper Club, he didn’t oversell it.

“I would love to think so, but we’re very early on. If you think back to people putting transcatheter heart valves in patients 15 or 20 years ago, people probably thought they were a little bit crazy and on the edge, and now it’s mainstream in most hospitals worldwide. I don’t know where it’s going to go in 15 or 20 years, but it’s nice to think that it might inspire other people to get creative and think about how we can make this a procedure for more than just the very, very sick with no other options.”

That framing matters, because the patient who received the world’s first VECTOR procedure was exactly that: someone with no other options.

A procedure invented for one patient

The NIH and Emory collaboration has a track record of tackling complex medical situations where no good options exist commercially. Dr. Bruce walked us through what made this case so unusual. The patient had a surgically replaced heart valve that had become severely narrowed over time. A second open-heart surgery was the obvious answer, but the patient was too sick to survive it.

“They’ll die on the table, essentially, if we try.”

So the team turned to placing a new valve inside the old one via catheter from the leg, a less invasive approach they use regularly. But in this patient, doing that would cause the old valve’s leaflets to swing open like trapdoors and block the left coronary artery, which supplies blood directly to the heart muscle. Block that, and as Dr. Bruce explained, you get a massive heart attack on the table with essentially 100% mortality without heroic intervention. Techniques exist to cut the leaflet down the midline so it opens like a window rather than a trapdoor, but this patient’s leaflets were so calcified that those weren’t viable either.

That’s when the idea came.

“He really was a patient with no options. So in talking about the patient, the idea came: if we’re going to block the artery, why don’t we just move it out of the way?”

The Saturday morning phone call that started it all

Dr. Bruce described the moment the plan took shape. It was a Saturday morning when Dr. Robert Lederman at the NIH called him.

“He said, I’ve just come off the phone with Vasilis, and we’re going to move the coronary artery. And I was like, okay, sure.”

Dr. Joye, who has been through the process of translating a novel catheter technique into clinical use, laughed at that. Moving a coronary artery through open-heart surgery is something cardiac surgeons do. Moving one through a catheter, without opening the chest, on a beating heart, had never been done.

What followed was a period of iteration in the animal lab at the NIH, working through the technique step by step until it was refined enough to attempt in a human. Dr. Bruce described spending four and five hours at a stretch in those animal sessions, working through failed attempts and learning from each one. Then the team analyzed the patient’s CT scans in detail, mapped out every projection angle and contingency, and went to Emory to attempt it for the first time in a human being.

“We were all pretty relaxed, to be honest, going in by the time we did it.”

What actually happened in that lab

Dr. Joye explained the mechanics for our audience in terms that cut through the clinical language. The coronary arteries originate at the base of the aorta, just above the heart. What the team did was create a new connection point higher up on the aorta, above where the new valve would sit, so blood could still reach the heart after the valve was deployed. They did this entirely through catheters.

One wire was advanced backward through the coronary artery and pushed out through the vessel wall. A second wire was burned through the wall of the aorta using an electrosurgical generator. Both wires then had to meet in the pericardial space, the natural cavity between the lining of the heart and the heart muscle itself, where a snare on one catheter captured the other wire and pulled it through. A covered stent was then deployed to bridge the two exit points, acting as the new conduit for blood.

The procedure itself took about five hours. The patient was in the lab for seven to eight hours in total.

There was one complication: bleeding into the pericardium. Dr. Bruce was matter-of-fact about it.

“That did happen at one point in the procedure, bleeding into the lining of the heart, into the pericardium, and we had to pop a needle in and drain that off. But again, expected. We reacted very quickly to that. There’s always unexpected things. Thankfully, none of those happened.”

He drew a clear distinction between expected complications, the ones you have a contingency for going in, and unexpected ones. The bleeding was the former.

Then came the moment of truth. After everything was in place, the team deployed the new heart valve. The old leaflets swung shut as predicted, blocking the original route to the coronary artery. Everyone waited to see whether blood would flow through the new catheter-built graft instead.

“It was quite reassuring to see good blood flow down into the coronaries through the graft, despite us having blocked it as predicted.”

How the patient did

The procedure was performed about a year before we spoke. Dr. Bruce delivered the update plainly.

“The patient, unfortunately, is no longer with us, but not related to a complication of this. There were a lot of other things going on that were life-limiting in the longer term for him as well. But when he passed away from other issues, there was no sign of any heart attack or ischemia or anything from the things that we did, which was of some reassurance after 9 or 10 months.”

A second patient has since undergone a version of the procedure involving both coronary arteries. The technique is being refined.

Where this could go

Dr. Bruce was thoughtful about the road ahead. He sees potential applications beyond the specific valve scenario that prompted this first case, including calcified lesions where coronary arteries meet the aorta, stents that fracture or fail to expand, and eventually more traditional coronary bypass grafting. He even sketched out a future worth imagining:

“You could imagine a world where you can have a robotic off-pump Lima to LAD, and then vector grafts to the circumflex and right. Those kind of things, we’re thinking.”

Dr. Joye, who knows from experience what it takes to get from a novel idea to something that works reliably in a broad range of hands, named the real challenge ahead.

“Doing it is one thing in a 7- or 8-hour procedure, but breaking it down to something that can be done in 90 minutes in kind of anybody’s hands is really the challenge.”

VECTOR is not the end of open-heart surgery. But it is a documented, peer-reviewed proof that a coronary bypass can be performed through a catheter on a beating heart without cracking a chest. That has never existed before. And if the history of procedures like TAVR tells us anything, the distance between a first-in-human case and a mainstream standard of care can close faster than anyone expects.

Watch the full conversation at the top of this article.

For more information you can also call the Global PAD Association’s Leg Saver Hotline at 1-833-PAD-LEGS

A new CTO joined an organization and asked for the system architecture.

Three days later, a PDF arrived. 112 boxes. 47 microservices. Two labeled “legacy (do not touch).” Lines crossing so many times, the diagram looked less like documentation and more like a subway map drawn by someone who had never ridden a subway.

She asked: Who designed this?

Nobody did.

Every box had a story. Every story made sense on the day someone added it. A cache for performance. A config service for flexibility. A second API gateway because migrating off the first one kept getting pushed to next quarter.

Reasonable decisions. Every one of them.

The collective result consumed 40% of the engineering budget on maintenance, shipped features in weeks that should take days, and produced 2-3x longer delivery times than simpler systems doing the same job.

This is the Complexity Trap. And it has three properties that make it so persistent: it is easy to enter, nearly invisible from inside, and it actively resists exit.

The new series starting today on the Simplicity-First Philosophy publication is about this trap. What it looks like from inside, why smart teams build it anyway, how to know you are in it, and how the Three Filters create a way out.

“The System Nobody Designed,” covers recognition. Five patterns that identify the trap. A diagnostic you can run on Monday morning. And the ego-protecting reframe that makes the conversation with leadership possible.

If the 112-box diagram sounds familiar, this series is for you.

The Simplicity-First Philosophy

The System Nobody Designed

This is Part 1 of a new series around The Complexity Trap…

Read more

7 months ago · Chris "Woody" Woodruff

Your cloud bill is 34% over budget. Nobody is responsible.

Not because people are hiding. Because the structure makes responsibility invisible. The platform team points to the product teams. The product teams point to traffic spikes and necessary headroom. Every explanation is true. The bill keeps growing anyway.

Essay 5 of my Economics of Software Architecture series explains why. It is called “The Tragedy of the Cloud Commons,” and it is live now on my Simplicity-First Philosophy publication.

The argument borrows from Garrett Hardin’s 1968 paper in Science. When a shared resource has no individual cost for consumption, rational actors will collectively over-consume it. Your cloud infrastructure is that shared resource. The platform budget is the pasture. Each team is a herder. Over-provisioning is the extra sheep. The benefit (performance headroom, your service not being the one that fails) is private. The cost (a larger bill) is socialized. Every team’s incentive is to over-provision. And $44.5 billion in projected cloud waste for 2025 is the aggregate result.

The essay diagnoses why FinOps addresses symptoms but not the incentive structure. It breaks down the four failures of chargeback: attribution (shared infrastructure recreates the commons inside the chargeback system), gaming (teams manipulate allocation rules), granularity (the feedback loop never reaches the person writing the Terraform file), and the architecture ceiling (chargeback cannot reduce costs below the floor the architecture sets).

Then it draws on Elinor Ostrom’s Nobel Prize-winning commons governance research to propose mechanisms that work: team-level budgets with architectural constraints, cost-per-feature as the unit metric, and the finding that simplifying architecture saves 60-90% while right-sizing saves 10-15%.

The biggest cost lever is not cost management. It is architecture.

Read it here:

The Simplicity-First Philosophy

The Tragedy of the Cloud Commons

The Bill Nobody Owns…

Read more

7 months ago · Chris "Woody" Woodruff

Nobody has ever calculated the interest rate on your technical debt.

Not approximately. Not roughly. Not at all.

Teams talk about technical debt constantly. They calculate it almost never. Ward Cunningham gave us the metaphor in 1992, and we took the language without doing the arithmetic. “We have some tech debt we should address” became the industry’s most comfortable way to avoid quantifying a problem that costs US companies $1.52 trillion annually.

Essay 4 of my Economics of Software Architecture series does the arithmetic. It is called “Technical Debt Has an Interest Rate,” and it is live now on my Simplicity-First Philosophy publication.

The essay maps every component of financial debt onto its technical equivalent. Principal: the gap between what was built and what should have been built. Interest rate: the additional time every task takes because of accumulated shortcuts (33-50% for typical teams, over 100% for severely indebted codebases). Carrying cost: $495,000 per year for a 10-person team losing a third of its capacity to maintenance. Default: the point where all engineering effort goes to servicing existing debt and no new value can be created.

The Simplicity-First Philosophy

Technical Debt Has an Interest Rate

The Loan Nobody Underwrote…

Read more

7 months ago · 1 like · Chris "Woody" Woodruff

For millions of people, that is exactly their reality, and most of them have been told there is nothing more that can be done.

On a recent episode of The Heart of Innovation on KDOW, my co-host Dr. John Phillips and I went deep on a procedure that most patients, and honestly many physicians, don’t even know exists yet. It’s called renal denervation. It’s FDA-approved. And as of October 2025, it’s covered by Medicare.

We were joined by two people who have spent over a decade inside this technology: Julie Trudel, Medtronic’s Senior Director of R&D, and Jason Fontana, VP of Global Marketing and Renal Denervation General Manager. To understand why this procedure matters, you first have to understand something about your kidneys that most people are never told.

The Nerve Pathway Pills Can’t Reach

Most people know kidneys filter waste and manage fluid. What most people don’t know is that a web of sympathetic nerves runs from your brain, down your spine, and wraps directly around your renal artery, and those nerves have a powerful hand in controlling your blood pressure.

“Those sympathetic nerves,” Julie explained, “like a little mesh of spaghetti that runs around the renal artery, they control the tone of your artery and dictate how much resistance to flow that artery will present to the body.”

Standard blood pressure medications target the kidneys’ hormonal systems, things like renin and fluid retention. But none of them directly target this nerve network. Which means for some patients, no matter how many pills they take, there’s a signaling problem running in the background that medication was never designed to reach.

In a healthy system, those nerves respond to stress and then stand down. In many patients with resistant hypertension, they never stand down. Jason described it plainly: “In a lot of patients with high blood pressure, that sense that everything is amped up, these nerves are constantly firing.” The body stays locked in a permanent fight-or-flight state, and the pills aren’t built to address it.

Doctors understood this nerve connection as far back as the 1930s. Their solution was to open patients up near the spine and physically cut the nerves. “Quite often when you do it surgically, these are hard to see,” Julie said, “and you may cut more than what you really should be cutting.” It worked, but at a real cost, and it faded from practice once blood pressure medications arrived.

Then catheter technology changed the equation. By the mid-2000s, the question was no longer whether those nerves could be calmed. It was whether you could do it without a single incision.

A catheter goes into the renal artery. Energy is applied against the vessel wall. Julie asked us to try something during the show: rub your hands together quickly. Feel the warmth? That’s the principle.

“What we’re doing with that little catheter, we’re bringing energy right against the vessel wall,” she said. “That energy makes the tissue around the renal artery vibrate like you did with your hand. By generating all this vibration, the nerves end up warming up just enough to a point where their activity level gets interrupted.”

No cutting, no implant, nothing left behind in the body.

“What we’ve been able to figure out,” Jason added, “is that you make this one spot, this one change, interrupt the signaling in the kidney, and that calms down all these nerves throughout the body.”

Getting to that moment of clarity, though, required surviving a crisis that nearly killed the technology entirely.

January 13, 2014

Jason remembered the date without pausing.

“Very cold day in Minneapolis. We were in a room with our CEO, Omar Ishak.”

The Symplicity HTN-3 trial had just produced results that seemed to say the procedure didn’t work. The kind of results that end programs. The kind that send teams home.

Ishak asked three questions. Is it safe? “It’s completely safe. No safety signal at all.” Do you think it works? “Yes, we do. And this is why.” Then came the last one, which Jason described as “not funny at the time, but funny now.” The CEO looked at them and said: “This is why we do research.”

The program survived, though barely.

“It was close to being dead,” Julie said. “I can only be so grateful for the general manager, Jason, Nina, Sean Salman, and Jason Wyman, who went in front of our CEO and advocated for it. It took champions.”

They went back into the data. Over 600 separate analyses of that one trial. “We knew every angle,” Jason said, “and everything that kind of went wrong.” Two problems kept surfacing. The original device required manual, point-by-point ablation: move the catheter, fire, move again. No two physicians performed it quite the same way, and no two patients got quite the same treatment. And critically, the team had no reliable way to confirm whether patients were actually taking their medications during the trial. Without that, they couldn’t cleanly separate the procedure’s effect from the noise.

Julie redesigned the catheter from the ground up. The new version, called the Spiral, applied ablations in a corkscrew pattern, ensuring consistent contact with the vessel wall regardless of who was performing the procedure. They restructured the trials to include medication monitoring. Then they started over.

What kept them going was a letter.

A man in his seventies from Florida had wanted to enroll in HTN-3 but couldn’t find a participating hospital near his hometown. So he paid out of pocket and flew to Germany to have the procedure done. His blood pressure dropped. He came off medications that had been causing him terrible side effects. And when HTN-3 failed and it looked like the technology might disappear, he sat down at a typewriter and wrote to Medtronic.

“Dear Medtronic, I want to tell you, keep continuing this procedure.”

The letter worked its way through the company until it reached Julie’s desk. Jason still remembered the patient’s words: “I got my life back.”

That letter, from a man who flew to another country and typed his case on a typewriter because he wanted others to have what he had, carried a team through 600 analyses and a near-death moment in a Minneapolis conference room, all the way to FDA approval in November 2023.

As Dr. Phillips said at the top of the show, quoting Babe Ruth: “It’s hard to beat a person who never gives up.”

Now the question is whether patients know this option exists…because the healthcare system, as Dr. Phillips described it, is not doing a great job of making sure they find out.

If You’ve Been Told Your Blood Pressure Is Uncontrollable

He called it a chronic “pass the buck” problem with hypertension. A cardiologist spots elevated pressure, adds it to the notes, tells the patient to stay on their meds and talk to their primary care doctor. The primary care doctor assumes the cardiologist would have acted if it were serious. A nephrologist maybe gets looped in eventually. The patient moves through the system and nobody owns the problem.

“Very few patients are controlled appropriately,” Dr. Phillips said. “And it’s often a pass-the-buck kind of treatment.”

Renal denervation is designed for the patient stuck in that loop, someone already doing everything right who still can’t get their numbers down. Jason described the ideal candidate clearly: “You’ve done lifestyle management, you’ve done the right thing. You’re taking your medications, you may be on one, two, three, four medications, and your blood pressure is still high. You’re doing the right thing, but you need a little help.”

Not everyone with high blood pressure qualifies; the indication is specific to uncontrolled hypertension in patients who have already exhausted the conventional options. And it doesn’t replace medication. Dr. Phillips put it simply: “Think of it as an airbag in your car. But always put your seatbelt on too.”

As for the procedure itself, it runs about 15 to 20 minutes under sedation, a catheter goes in through the groin artery with the wrist approach in development, and patients go home the same day. “Your blood pressure might change a little,” Dr. Phillips said, “so just be cognizant of that. We’re always following these patients closely.”

You Deserve to Know This Exists

The Symplicity Spyral received FDA approval in November 2023. Medicare finalized national coverage in October 2025. The clinical data now stretches to three years and continues to strengthen, with blood pressure reductions remaining durable well beyond the procedure date. The only thing missing is patients who know to ask for it.

If you’re on multiple blood pressure medications and your numbers are still high, bring your home readings to your next appointment and ask your doctor directly about renal denervation and the Symplicity Spyral system. Don’t wait for it to come up. In a system that tends to pass the buck, the patient who advocates for themselves is the patient who gets answers. This procedure exists. It’s covered. And now you know to ask for it.

The Heart of Innovation airs on KDOW AM 1220, brought to you by the Global PAD Association at padhelp.org. Hosted by Emmy Award-winning journalist and Global PAD Association founder Kym McNicholas and interventional cardiologist Dr. John Phillips, founder of Save My Piggies Health and Wellness.

That’s where I first met Michael Lepp.

While most people covering NASCAR were chasing the story on the track, Michael was already asking a different question entirely. What would happen if you treated the pit crew like the elite athletes they actually were? Not the mechanics pulling double shifts under the car before coming out to practice tire changes. Not the guys whose names only got mentioned on the radio when something went wrong. The athletes. The ones whose foot speed and hand-eye coordination and ability to perform under pressure in a fire suit at 90 degrees were quietly winning and losing races while everyone watched the driver.

More than 20 years later, I finally got the whole story on the air. On a recent episode of The Heart of Innovations, live on AM 1220 KDOW, the number one healthcare innovation radio program in the San Francisco Bay Area and the number one Women in Innovation Podcast in the nation according to Feedspot 2025, Michael joined me and my co-host Interventional Cardiologist Dr. John Phillips for an hour that covered pit road, championships, bad days, and what performance under pressure actually looks like when you strip away everything that doesn’t matter.

Michael is an exercise physiologist. His company is Zone 1 Human Performance. He spent fifteen years on the road with Joe Gibbs Racing, thirty-two weeks a year, building something that didn’t exist before he arrived: a pit crew treated as a full-time athletic program. Joe Gibbs won three Super Bowls as an NFL head coach with three different quarterbacks, none of whom are going to the Hall of Fame, a fact Michael mentioned with the particular satisfaction of someone who has made that point many times. When Gibbs moved into NASCAR, his son JD ran the race team. JD rode his bicycle in the same office park where Michael had set up his cycling physiology practice. One day he walked over and made Michael an offer: free office space inside the 80,000-square-foot Joe Gibbs Racing facility if Michael could find a way to make pit stops faster.

“Free office space?” Michael told us. “Sure. Why not.”

That’s how the S-12 Project started.

When Michael arrived, pit stops were running fifteen to sixteen seconds. A full four-tire stop meant six men going over the wall simultaneously: two tire changers hitting five lug nuts each in under a second, two tire carriers moving 80-pound tires, a jackman lifting a 3,000-pound car on two pumps, and a fueler managing two 100-pound gas cans. The margin for error was measured in tenths of a second. Miss a single lug nut and you lost four-tenths on the stop. Miss two and you lost eight-tenths. In a sport where passing on the track had become nearly impossible because of aerodynamics, the pit stop had become the race within the race. Anywhere from five to twelve pit stops per race, and if you could pass cars on pit road with a faster stop, you came out ahead of drivers you couldn’t touch on the track.

Before Michael prescribed anything, he spent three months watching.

“I’m a big diagnose before you prescribe,” he said.

What he diagnosed wasn’t a training problem. The men doing the pit stops were also the mechanics building the cars, working eight to twelve hour days before coming out to practice. Nobody was treating this as a dedicated athletic job. Nobody had a plan. The first thing he told JD Gibbs was that had to stop. These men needed to be full-time athletes, nothing else. JD said yes.

The goal Michael set was under twelve seconds. People told him he was full of it.

What followed wasn’t one breakthrough. It was what Michael called marginal gains, meaning the accumulation of small improvements across every variable until the sum of them changes the outcome. New Balance developed a fireproof athletic shoe because the boots the crew had been wearing were costing them foot speed. The pit stalls got sprayed with adhesive so crew members could cut around the car without slipping. A massage therapist was hired. A two-hour pregame preparation process was built, the way professional sports teams warm up before a game. JD Gibbs handed Michael a company credit card with one instruction: use it to take care of these guys, dinner, their families, whatever they need on the road. Michael had learned from cycling physiologist Alan Lim that the most reliable predictor of whether an athlete was going to underperform had nothing to do with fitness numbers. It was whether they had broken up with their girlfriend or had a family crisis at home.

They got the stops under twelve seconds.

Then they won championships.

And when the pit crew started winning bonus money that JD distributed across the whole team rather than keeping it, the mechanics who had resented the outside athletes decided they loved them.

It was a long tough road to get to that point with trial and error.

At the end of the show, Michael recalled the early days…and one moment stands out:

Denny Hamlin was leading a race at Darlington, one of the old classic tracks, the one they were racing at again the weekend we recorded, when the crew had a disastrous final pit stop, what the team calls the money stop, and Hamlin went from first to thirteenth. Michael packed up with the crew, got in the car, and started the drive back to Charlotte. On the way he turned on NASCAR Radio. The crew chief was being interviewed. While the crew sat in Michael’s car listening, the crew chief announced on air that the pit crew had cost them the race and they would all be unemployed.

“They were sitting in my car,” Michael said. “We all just got fired on the radio.”

JD wouldn’t let the firing stand. And that same No. 11 crew, with Mike Ford as crew chief, went on to become what Michael called the fastest pit crew in the history of the sport. “I wish they could go to the Hall of Fame,” he said. “They don’t put pit crew guys in the Hall of Fame yet, but hopefully they will at some point.”

Dr. John asked Michael what he would say separates the fastest crews from everyone else. Michael didn’t hesitate. It wasn’t the training. It wasn’t the equipment. It was how they handled the bad days. How they recovered from the tough days and came back. He told the story of JD Gibbs walking out to the practice facility after a bad session to find an assistant coach in a tirade, threatening to run the crew into the ground as punishment. JD waited for it to end, stepped forward, and said to the seven men standing there: “Go home. Have dinner with your family. Hug your kids. We’ll get back at it tomorrow.” Michael said he never forgot it. “Not, I didn’t grind hard enough. Not, I’m a failure type of a thing.”

He said the same is true for the cardiac and PAD patients he has worked with throughout his career. The training program he writes for a cardiac patient or a PAD patient is no different in its structure from the program he wrote for the pit crew: multifactorial, individual, built around a plan, with a mental component alongside the physical one. The patients who improved most were the ones in his group program, the Dawn Patrol, where eventually he could sit in the bleachers because the group took care of itself. Long-term compliance, he said, is about the group you’re with. “Just because you’re walking,” he said, “doesn’t mean the pain and discomfort you have to tolerate to make improvements and develop that collateral circulation is any different than any athlete I work with.”

The number one topic Michael gets asked to speak on, now that he’s retired from the road, is performance under pressure. He has lived it at the highest level of a sport most people never think of as athletic, with people whose names only got mentioned when they failed, building something from nothing on a free desk in an office park in Charlotte. The key, he said, isn’t the good days. It never is.

The Heart of Innovations airs live every Saturday on AM 1220 KDOW in the San Francisco Bay Area and is available on demand at PADhelp.org. If you or someone you love is experiencing leg pain when walking that eases with rest, color changes in the feet or lower legs, wounds that won’t heal, or unexplained numbness or tingling, call our free Leg Saver Hotline at 1-833-PAD-LEGS. To connect with more than 12,000 PAD patients supporting each other every day, join our Peripheral Artery Disease (PAD) Official Group on Facebook.

Essay 3 of the Economics of Software Architecture series is live on my Simplicity-First Philosophy publication.

It’s called “The Principal-Agent Problem,” and it answers the question that Essays 1 and 2 both raised: if the architecture tax is so large and the opportunity cost so destructive, why do smart architects keep making decisions that maximize both?

The opening scenario: a senior architect proposes migrating the company’s modular monolith to Kubernetes. Six months and four engineers later, the deployment pipeline is sophisticated. The YAML files fill a repository. Eight months after that, the architect leaves. The LinkedIn announcement: “Led enterprise Kubernetes migration.” New role pays 40% more. Back at the original company, three engineers now maintain the infrastructure full-time.

This is not a story about a bad architect. It is a story about rational behavior in a system with broken incentives.

The research behind it: a 2021 ICSE study of 591 software professionals found that 82% believe trending technologies improve their career prospects. Both hiring managers and candidates acknowledge the emphasis is overstated relative to actual value. Neither side can unilaterally stop. The researchers called it Resume-Driven Development, and it is a peer-reviewed coordination failure with direct architectural consequences.

The essay also applies Michael Spence’s signaling theory (why complexity functions as a costly career signal with no natural ceiling), examines vendor capture (8.25 million workers trained in vendor-specific programs in the first half of 2024), explains why architecture review boards fail (the monitors share the monitored’s incentive structure), and proposes mechanism design solutions drawn from Elinor Ostrom and game theory.

The architect who builds a complex system and leaves has made a rational economic decision. The irrationality is in the system that rewarded them.

Read the full essay here:

The Simplicity-First Philosophy

The Principal-Agent Problem

The Kubernetes Migration That Built a Career…

Read more

8 months ago · 1 like · Chris "Woody" Woodruff

Essay 2 of the Economics of Software Architecture series is live on my Simplicity-First Philosophy publication.

It’s called “Opportunity Cost Is the Cost Architects Never Count,” and it picks up where “The Architecture Tax” left off. Essay 1 asked what your architecture costs. This one asks what it cost you not to build.

The opening scenario: a product team finishes a six-month microservices migration. The deployment pipeline is elegant. The service mesh is configured. The architecture review board signs off. Everyone is proud. Meanwhile, 47 customer-requested features sit untouched in the backlog. Three competitors have shipped capabilities users have been asking for. NPS has dropped four points.

The team built something impressive. They just didn’t build anything customers wanted.

That’s opportunity cost, and it’s the most expensive line item in software because it’s the one nobody measures. The essay makes it measurable.

Some of the research that went into it: McKinsey found that a product six months late to market loses 33% of profit over five years. Being 50% over budget? Only 4%. Delay is 8x more expensive than overspend. Segment spent $450-600K per year in direct costs maintaining 140 microservices, but the opportunity cost (12 unshipped features, lost feedback cycles, eroded competitive position) ran $2-5 million. DORA data shows elite performers deploy on-demand, running 365 experiments per year. Low performers deploy monthly: 12 experiments. That’s a 30x learning gap created entirely by architectural choices.

The essay also applies lean manufacturing’s seven wastes to software architecture and introduces an opportunity cost ledger you can run against your own sprints.

This is the invisible twin of the Architecture Tax. The money you spent is on the invoice. The money you lost is not.

Read the full essay here:

The Simplicity-First Philosophy

Opportunity Cost Is the Cost Architects Never Count

The Sprint That Built Nothing Users Wanted…

Read more

8 months ago · 1 like · Chris "Woody" Woodruff

Quick note today to point you toward something I’ve been working on for months.

I just published the first essay in a six-part series called “Economics of Software Architecture” over on my Simplicity-First Philosophy publication. It’s called “The Architecture Tax,” and it opens with a scene you’ll probably recognize:

A team of engineers stands around a whiteboard. In 45 minutes, they commit the organization to an infrastructure pattern that will cost between $200/month and $65,000/month. Nobody has a spreadsheet open. Nobody has consulted finance.

If anyone proposed a $500K annual expenditure without a business case, they’d be shown the door. Yet architects make decisions of equal magnitude in whiteboard sessions every week.

The essay digs into why this keeps happening and what it actually costs. Some of the numbers that went into it:

$44.5 billion in projected cloud waste for 2025. Amazon’s own Prime Video team discovered that its distributed architecture failed at 5% of expected load, then cut costs by 90% through consolidation. 37signals left AWS and saved $2 million per year. 42% of microservices adopters are now consolidating back.

It also introduces a Total Cost of Architecture calculation that covers the five cost categories most organizations never track: infrastructure premiums, operational overhead, coordination burden, cognitive load, and opportunity cost. There’s a diagnostic at the end you can run against your own systems.

This is the first of six essays. Each one applies a different economic concept to a specific failure in the industry's decision-making process. Opportunity cost, principal-agent theory, compound interest on technical debt, commons economics, and sunk cost fallacy are all coming.

Read the full essay here:

The Simplicity-First Philosophy

The Architecture Tax

The Whiteboard That Costs More Than Your Office…

Read more

8 months ago · Chris "Woody" Woodruff

I think it’ll change how you look at your next whiteboard session.

I’ve known Meredith Perry long enough to know she doesn’t mess around. The first time I really understood how her brain works, we were in the back seat of a car driving from the airport to Sedona. Everyone was complaining about swollen ankles from the flight. Most people just groan and move on. Meredith immediately started designing a product…cute sandals that could disguise flight-puffed ankles. She called them “cankle flops.” I was fascinated. That instinct, to see a problem and immediately engineer a solution, is just how she’s wired.

So when she told me she’d built a headband that reads your brainwaves and uses precisely timed sound pulses to guide your brain from wakefulness into sleep…I wasn’t shocked. I was curious. And after sitting down with her on The Heart of Innovation, the show I co-host with interventional cardiologist Dr. John Phillips, I walked away convinced this is one of the most important health technologies I’ve covered in years. Not just because of what it does for sleep, but because of what sleep does to your heart.

When Sleep Became a Cardiovascular Variable

Here’s what I didn’t fully appreciate before this episode: sleep is no longer just a lifestyle concern. It’s a cardiovascular variable, and the medical community is treating it that way.

A 2022 study in the Journal of the American College of Cardiology followed more than 7,000 adults and found that people sleeping fewer than six hours a night faced a significantly higher risk of atherosclerotic cardiovascular disease compared to those sleeping seven to eight hours. The American Heart Association now lists sleep duration as one of eight pillars of cardiovascular health in its Life’s Essential 8 framework. Research in the European Heart Journal has tied short and fragmented sleep to elevated risks of coronary heart disease and stroke.

Dr. John Phillips, who treats cardiovascular and vascular patients every day, confirmed what the research shows. “Statistically speaking, 10 to 15 percent of all adults have insomnia,” he told me on air. “And consistently poor sleep puts real stress on the cardiovascular system… elevated blood pressure, disrupted heart rate, increased sympathetic tone. We see it in our patients all the time.”

Six and a Half Years to Get Here

Meredith launched Elemind in 2019. She thought it would take two years to reach the market. It took more than six. Seven hardware iterations. Four years of getting the comfort right because, as she put it with characteristic bluntness, if people won’t wear it to sleep, none of the technology matters.

“It would be massive. But it’s life or death,” she said. “Like, if you’re selling a product that people are going to wear to sleep and it’s not comfortable… it doesn’t matter how good your technology is. They’ll just toss it out and then your company goes bankrupt.”

So she waited. And iterated. And waited some more. The version on the market today is lighter than a kiwi fruit, pillow-soft on the sides, and designed to work whether you sleep on your back, your side, or your stomach. I asked about stomach sleepers specifically — I’m one — and she pointed out that even stomach sleepers turn their heads to breathe. The device is thin enough to handle it.

How a NASA Researcher Started Thinking About Your Brain

Here’s the part of the origin story I found most fascinating. Meredith didn’t come to sleep through insomnia. She came to it through a much bigger question: what if medicine could intervene earlier, before disease sets in, without pharmaceuticals that alter the whole body systemically? What if the brain itself could be influenced from the outside, in a targeted way?

That question led her to MIT neuroscientist Dr. Ed Boyden, one of the leading figures in neuroscience, and conversations about what she calls read-write neurotechnology. Not just measuring the brain’s electrical activity, the way an EEG does passively. But actually writing back to it. Interacting with it. Changing it.

Dr. Boyden and Meredith’s other co-founders had already been developing neuromodulation techniques to do exactly that, and their first application wasn’t sleep at all. It was tremor control. They showed that the same type of precisely timed acoustic stimulation could help someone with essential tremor or Parkinson’s disease physically stop shaking. The brain’s patterns, it turns out, can be interrupted and redirected from the outside using sound.

“If you can change the brain, you can change behavior,” Meredith explained. “And by behavior, I mean you can move someone from an awake state to a sleep state. Sleep was our first application — but it won’t be our last.”

Sleep made sense as the entry point for a few reasons. It’s universal…everyone sleeps, or tries to. The transition from wakefulness to sleep is one of the most well-mapped brainwave sequences in neuroscience. And it’s a problem that affects tens of millions of people who are desperate for something that isn’t a pill. Meredith saw a clear lane and took it.

How It Actually Works — Because I Made Her Explain It Simply

I’ll be honest: I asked Meredith to break this down for the lay person, because neuromodulation is not exactly dinner table vocabulary. Here’s what she told me.

The brain is an electrochemical organ, constantly producing electrical activity that we can measure from the outside using EEG sensors, the same way an EKG measures the heart. Different frequencies tell us what state the brain is in. When you close your eyes and you’re still awake, your brain is producing high-frequency alpha waves. As you drift toward sleep, those frequencies slow down predictably.

Elemind has five EEG sensors embedded in the headband that read those brainwave patterns in real time. When the device detects patterns associated with wakefulness, it sends a brief pulse of pink noise…not through your ears, but through a bone conductor pressed against your forehead. The skull vibrates. Your brain interprets that as sound. And if the pulse hits at precisely the right moment in the brainwave cycle, it disrupts the wakefulness pattern.

“There’s a specific moment along the wave that, if you hit it with a stimulus, the pattern is maximally disrupted. It’s the timing that matters…not the sound itself.”

She compared it to an ocean wave. Hit it at the right angle at the right moment, and you can cancel it out. She called it noise cancellation for the brain. Once the device detects that you’ve actually fallen asleep, the stimulation fades. And if you wake up in the middle of the night, there’s a button on the underside of the band…what the Elemind team calls the go-back-to-sleep button…that restarts the whole process.

Later this year, they’re releasing a deep sleep stimulation feature via firmware update. That means people who buy the device today don’t need to buy a new one — it just gets better through software.

What I Really Wanted to Know: How Is This Different From My Oura Ring Collecting Dust?

I’ll be transparent about this: I got an Oura Ring years ago when I interviewed someone from the company. It sat in a box almost immediately. And I stopped wearing my Apple Watch because it kept pinging me in the middle of the night while supposedly tracking my sleep. I raised this with Meredith, and her answer was clarifying.

Most sleep wearables are read-only. They measure what happens and report it back to you in the morning. Elemind is read-write. It’s not tracking your sleep to show you data…it’s actively intervening while the transition is happening. Every sound pulse is a real-time response to your specific brain activity at that exact moment.

“That’s why you can’t just play pink noise from your phone and call it a day,” she said. “We have to read the brain in real time to know how to stimulate. Without that, it’s just ambient sound, which is very different from neuromodulation.”

That distinction matters more than it sounds. The difference between a babbling brook app and a device that reads and responds to your brain is the difference between hoping you relax and actually changing the electrical state of your brain.

The Clinical Trial She Didn’t Have to Do

Here’s something I respect enormously about Meredith: she ran a clinical trial even though she didn’t have to. Wellness devices don’t require FDA approval or peer-reviewed evidence. Most companies skip the science entirely. Elemind chose not to.

“There’s a lot of snake oil out there,” she said. “We will not make a single claim that isn’t backed by a clinical trial and peer reviewed in a scientific journal. All of our papers are in the Nature portfolio.”

The trial showed that 76% of people with sleep onset insomnia could fall asleep in roughly half the time when using Elemind versus their baseline. And this wasn’t self-reported, the brainwave data was scored by independent polysomnographers who didn’t know which condition the participants were in. No bias. Just brainwaves.

Real-world data backs it up too. From approximately 10,000 users in 2025, people were consistently falling asleep in an average of 11 minutes — regardless of the day of the week or the season. That consistency, she noted, is genuinely unusual. Sleep patterns typically vary. Elemind’s apparently don’t.

One Thing Elemind Is Not, And One Surprising Partnership

I want to be clear about something, because viewers asked during our live taping and it’s worth addressing directly: Elemind does not treat obstructive sleep apnea. Sleep apnea is a structural problem…the airway collapses, oxygen drops, the brain wakes you up. That requires a physical intervention, and the CPAP machine remains the standard of care. Elemind cannot and does not replace it.

But here’s what’s interesting: Elemind is partnering with ResMed, the leading CPAP manufacturer, on a clinical study…not to treat sleep apnea, but to study whether Elemind can improve CPAP adherence. The CPAP has a notorious compliance problem. A lot of people get prescribed it and stop using it because falling asleep with a mask strapped to your face is genuinely uncomfortable. The hypothesis is that if Elemind can help someone fall asleep faster, the discomfort of the mask becomes easier to tolerate and more people actually stick with the therapy. If that holds up, a wellness device becomes a clinical tool — just not in the way viewers assumed.

There’s also a pain angle that surfaced near the end of our show. A viewer with peripheral artery disease called in — he described lying awake all night dangling his legs over the bed because of ischemic pain, waiting on insurance authorization for a procedure to fix blocked arteries. Meredith mentioned that Elemind has conducted a trial using its deep sleep stimulation technology alongside sedation anesthesia and found participants could tolerate more pain before waking from the procedure. Whether that translates to helping people sleep through chronic pain at home isn’t yet known. But the question is now being asked.

The Campaign That Made Me Love This Company

I have to talk about Sleeping with the CEO… because it’s one of the most creative, confident marketing campaigns I’ve seen in health tech.

Meredith takes a lawn chair into the streets of New York City. Washington Square Park. The High Line. Giants tailgates. Airplane cabins. She approaches strangers, asks them to lie down and put on the headband, and films them falling asleep. She naps alongside them. She calls the campaign Sleeping with the CEO.

“We got thrown out of Times Square by a police officer,” she told me. I loved that. “But the point was: if you can fall asleep in the middle of Times Square with Elemind on, you can fall asleep anywhere.”

What I find compelling about this isn’t just the boldness. It’s what it says about the product’s confidence. Sleep wearables have a notorious drawer problem…people buy them, wear them for a week, and abandon them. The fact that Meredith is out here demonstrating this on skeptical strangers in the loudest city in America, and it’s working, tells me something about how much she trusts what she’s built.

Best of Sleeping With the CEO

What’s Next — and Why It Matters

Sleep is just the beginning. As Meredith put it: “Sleep is our Trojan horse into the rest of the brain.” The longer vision is a device that tracks and optimizes brain health overnight — starting with sleep, moving toward tremor control, cognitive health, and beyond. The technology she’s built can, in principle, be integrated into headphones, eyeglasses, VR headsets, or anything that touches the head.

For now it’s a wellness device — not a prescription product — and it’s available directly to consumers. An optional subscription unlocks sleep data and advanced features. You can use FSA and HSA dollars toward the purchase.

I left this interview thinking about the patient who called in with his legs dangling over the bed at 3am. I thought about the CPAP machine sitting on somebody’s nightstand, unworn. I thought about Dr. John’s comment that sleep is now sitting beside cholesterol and blood pressure as a driver of cardiovascular disease. And I thought about how, for all of the data and the science and the seven iterations and the clinical trials, what Meredith Perry really built is something that actually works — on strangers, on planes, in Times Square, in the dark.

That’s not nothing. That might be everything. Learn more at elemindtech.com.

Citations

1. Dominguez F, et al. “Association of Sleep Duration With Atherosclerotic Cardiovascular Disease Risk.” Journal of the American College of Cardiology. 2022;79(15):1475–1485.

2. Daghlas I, et al. “Sleep Duration and Risk of Coronary Heart Disease and Stroke.” European Heart Journal. 2021;42(35):3549–3557.

3. Lloyd-Jones DM, et al. “Life’s Essential 8.” Circulation. 2022;146:e18–e43.

4. Makarem N, et al. “Sleep Duration and 24-Hour Blood Pressure Patterns.” Hypertension. 2020;75(2):497–505.

5. Christensen MA, et al. “Sleep Fragmentation and Incident Atrial Fibrillation.” Journal of the American Heart Association. 2023;12:e028942.

You’ve been in this meeting.

Six engineers. A whiteboard. Someone draws a clean architecture: one service, a relational database, a well-defined API. It handles every requirement in the spec.

Then the questions start. “What about international customers?” “What if we need a second payment provider?” “Shouldn’t this be event-driven?”

45 minutes later, the single-service design has evolved into four microservices, an event bus, and a configuration system for scenarios nobody has actually requested. The system that could have been built in three weeks will now take three months.

Nobody wanted this outcome. Every question was reasonable. Every addition was defensible.

So what happened?

I spent a long time thinking about this problem, and the answer turned out to be in a field I didn’t expect: game theory. Architecture reviews are social games with real status stakes. The prisoner’s dilemma maps directly onto them. Building a comprehensive plan makes you look thorough. Building something simple makes you look lazy. So everyone over-engineers, and the whole team loses.

But game theory doesn’t just diagnose problems. It fixes them. A branch called mechanism design asks: how do you rewrite the rules of a game so the winning strategy produces the outcome you actually want?

That’s what this essay is about. Three questions you can throw into any spiraling design review that change the direction of the conversation in seconds. Not principles. Not best practices. Concrete questions that restructure who wins the status game in the room, so that simplicity becomes the rational choice.

If you’ve ever watched a clean design get buried under hypothetical requirements, this one’s for you.

The full essay is over on my Simplicity-First Philosophy publication:

The Simplicity-First Philosophy

The Architecture Game

It’s Thursday afternoon, and six engineers are standing around a whiteboard. Someone has just drawn a clean, simple architecture for the new order processing system. One service. A relational database. A well-defined API. It handles every requirement in the spec. A junior developer could trace the request flow in ten minutes…

Read more

8 months ago · Chris "Woody" Woodruff

Larry “Shorty” Coleman delivered those words to lawmakers during the bipartisan relaunch of the Congressional Peripheral Artery Disease (PAD) Caucus.

A Harlem Globetrotter who has played basketball since he was eleven, Shorty built his life around movement. Conditioning. Endurance. The instinct to push through pain. When his leg began to hurt, he treated it like an athlete treats a cramp. Something temporary. Something manageable.

He was one of the patients who spoke on Capitol Hill at the caucus relaunch, alongside physicians, industry leaders, and another PAD patient, Dawn-Marie.

Both Shorty and Dawn-Marie rolled in.

Neither walked in.

They were not there for sympathy. They were there to explain how a disease more prevalent and deadlier than most cancers combined was allowed to progress unchecked until amputation became the outcome.

And how that progression did not have to happen.

Peripheral Artery Disease is not rare. It is poor circulation in the legs that increases cardiovascular morbidity and mortality. In high-risk patients such as those with diabetes, hypertension, hyperlipidemia, clotting disorders, or autoimmune disease, early testing can identify disease before it advances to tissue loss. In many cases, progression can be slowed with medication, risk-factor control, and coordinated vascular care.

That is what the physicians and patients who stood before Congress made clear. And that is what they discussed in depth on this week’s episode of The Heart of Innovation.

Dr. John Phillips and I invited Shorty, Dawn-Marie, vascular surgeon Dr. Bob Tahara, and interventional cardiologist Dr. Andrew Klein to share what was said during the relaunch of the PAD Caucus and why it matters now. The focus was direct: expand coverage for early PAD testing, require documented vascular evaluation before non-traumatic amputation, and address insurance delays and denials that stall limb-saving care while amputations move forward with far less resistance.

The relaunch centers on reviving the Amputation Reduction and Compassion Act, legislation that lost traction after Congressman Donald Payne Jr., who had PAD and championed the bill, passed away. The ARC Act would expand coverage for early PAD testing among high-risk patients and require documented vascular evaluation before any non-traumatic amputation proceeds.

For clinicians, those provisions address two persistent gaps. Too many high-risk patients are not screened early. Too many amputations proceed without comprehensive vascular assessment.

Shorty’s story underscores the first gap.

“Don’t take for granted it’s just a cramp,” he told lawmakers.

He described escalating leg pain and the assumption that it was muscular. He spoke about diabetes in his family. About going to the emergency room when the pain intensified. Looking back, he believes earlier specialist evaluation might have changed his trajectory.

Dawn-Marie followed him at the caucus relaunch.

She began with questions.

When you leave this building and walk to your car in the snow, she asked lawmakers, what does that require? When your child runs ahead of you at the park and you step onto wood chips to push them on a swing, what does that require? When you go to the beach and your children run toward the ocean, can you reach them?

She cannot.

But her message to lawmakers did not stop at life after amputation.

Before the amputation, the leg pain was severe enough that she would sit on the floor in public because she could not keep walking. She sought medical care and described worsening symptoms.

Doctors dismissed it.

She then had a heart attack.

She underwent two heart catheterizations.

The leg pain continued to intensify.

Still, she said, no vascular evaluation was performed. No PAD diagnosis was made. No coordinated assessment connected her cardiac disease with her limb ischemia.

That sequence is not isolated. It is why the ARC Act is back on the table.

Early testing for high-risk patients. Documented vascular evaluation before non-traumatic amputation. Connecting cardiac disease and limb ischemia instead of treating them as separate silos.

During the broadcast, I shared what we see through the Global PAD Association hotline. Patients are told it is neuropathy. Or diabetes. Or aging. They are reassured. When they finally get proper testing, the diagnosis is PAD.

When we actually get them tested, it is PAD.

And once they reach a physician willing to pursue true limb salvage, major amputation is often mitigated or prevented altogether.

Dr. Bob Tahara addressed what that work requires. Disease below the knee. Malleolar reconstructions. Time-intensive procedures that not everyone is trained or willing to perform.

“You have to be willing to go below the knee,” he said. “Not everybody’s capable of doing that.”

He also made a point that resonated in the room. Amputation has existed for as long as surgery has existed. Revascularization is comparatively recent.

“Amputation’s been around for a long time,” he said. “Revascularization is really a recent technology.”

Yet reimbursement systems often treat them as though the older solution is the default.

The conversation turned to insurance pre-authorization. I asked how it is possible that amputations receive approval so readily, while revascularization procedures are delayed, scrutinized, or denied.

Patients call the Global PAD Association’s Leg saver Hotline in the middle of the night.

“I need hope. I need help,” they say. “Walk me through dangling my legs. Pacing. Trying to get blood back into my feet.”

They wait. Tissue deteriorates. Two weeks later, a denial.

Meanwhile, a major amputation moves forward.

Dawn-Marie added another layer.

“There are a lot of doctors that think you’re going to get a prosthetic, like no big deal,” she said. “You’re going to get a prosthetic the moment you have the amputation. Within a year, you’ll be walking like no problem.”

Then she addressed physicians directly.

“Stop promising,” she said. “If you’re a physician or a surgeon, stop giving the false hopes of walking within the first year. I’m almost five years out, and I still don’t walk.”

The human cost does not end in the operating room.

Dr. Tahara noted that once patients reach a major level amputation, rehabilitation is difficult and outcomes are often limited. And PAD rarely affects only one limb.

“Disease burden is always bilateral,” he said.

Dawn-Marie knows that reality. Her remaining leg is still diseased. Physicians are cautious after what happened with the first.

“I still have young children,” she said. “I still have to go to the supermarket. I have to keep going. I can’t afford to stop and lose my other leg.”

The relaunch of the Congressional PAD Caucus brings these stories back into the room where policy is shaped.

Shorty assumed a cramp would pass.

Dawn-Marie sat on the floor in public because the pain was overwhelming, survived a heart attack and two cardiac catheterizations, and still was not evaluated for PAD until amputation was unavoidable.

The physicians who stood beside them are not asking for sympathy. They are asking for standardization. Early testing in high-risk patients. Documented vascular evaluation before amputation. Reimbursement structures that do not delay limb salvage while accelerating limb loss.

We already know how to detect PAD.

The question is whether we will do it consistently.

Recognition is not optional. It is the difference between intervention and regret.

About the PAD Pulse Alliance and Get a Pulse on PAD Campaign

The relaunch of the Congressional Peripheral Artery Disease Caucus was supported by the PAD Pulse Alliance, a coalition of leading cardiovascular and vascular organizations working to improve PAD awareness, screening, and treatment standards.

Founding members include the Association of Black Cardiologists (ABC), the Society for Cardiovascular Angiography and Interventions (SCAI), the Society of Interventional Radiology (SIR), and the Society for Vascular Surgery (SVS). Supporting partners include the American Podiatric Medical Association, the CardioVascular Coalition, the CLI Global Society, Corazon, the Global PAD Association, the Outpatient Endovascular and Interventional Society, the Preventive Cardiovascular Nurses Association, and the Society for Vascular Medicine.

The initiative is driven in part through SCAI’s Get a Pulse on PAD campaign, which aims to educate clinicians and the public about PAD risk factors, symptom recognition, and the importance of early testing. The campaign is supported by industry partners including BD, Biomedix, and others committed to improving early detection and limb preservation.

Together, the coalition is focused on advancing policy solutions that expand high-risk PAD screening, require vascular evaluation before non-traumatic amputation, and reduce preventable limb loss nationwide.