A new pop up just opened in DC on 7th Street NW, between G and H. You love to see it.

To state the obvious: I have been following blogs for much longer than I’ve had one. A version of what now goes under “Infinite Regress” first started in October 2010, shortly after I moved to the US. Most of it was in Serbian and now available elsewhere but in 2012 I started blogging in English and, well, here we are.

There is only a handful of blogs which I have been following from before that time. The list does not include Marginal Revolution, which I didn’t know about until around 2015, when a hematology attending at NHLBI mentioned it during rounds. ⊕ [Note: Here is the too much information part, and not particularly relevant to the topic at hand: the attending was Neal Young, who also introduced me to Edward Tufte; it was during the post-Tuesday clinic roundup of patients with aplastic anemia, which were always fun; and it was him showing a video of a bear which Tyler Cowen linked to the day before. Why I can remember those facts but not to pick up ricotta cheese at the store as instructed to by my wife is one of those small mysteries of life. I do also remember being somewhat surprised that the super-smart and erudite Young was impressed by a stupid bear video. ] Andrew Gelman’s “Statistical Modeling…” also wouldn’t make the cut: even though he started blogging in 2004, around the time I discovered Bloglines, I wouldn’t become a subscriber until some time during covid lockdowns during a brief period when I thought I had enough time to read much more than I actually could and ultimately and inevitably overcommitted. Yet I try to model their regularity (consciously) and irreverence (not as consciously, more as a permission), if not Cowen’s positions as of late.

Then there are the blogs which are now dead, defunct, or a shadow of themselves. Many of those productivity-adjacent. Stuff like Lifehacker, 43 Folders, Kevin MD. These I couldn’t say were explicit current influences in format or style, but I do still have a GTD and a medicine tag and I update both fairly frequently.

There are only three blogs I can think of that I have been following pre-blogging and still do, with some interruptions in between. Two of them should not be a surprise to even a casual recent reader: John Gruber’s Daring Fireball and Dave Winer’s Scripting News. ⊕ [Note: I fought hard against finshing the title of this post with a (the last one may surpirse you) because this is one of those cases where the clickbaity headline may actually have fit. ] The third, though, fell off my radar during the last great feed reader reshuffle as it has several more times over the last 22 or so years I have been a not-so-faithful follower: Dubious Quality by Bill Harris, which has gone from being predominantly about gaming to game developing to, well, something that is less focused than even what you are reading here so I would not exaggerate if I called DQ the ur-influence of “Infinite Regress”.

And a few decades before @jtr’s push to write more emails I was a fairly regular emailer to Harris. In fact, my very first email to him, my Gmail archive tells me, was dated August 24, 2004 and had the subject line of “RSS feed, please”. I haven’t changed much, have I?

• Greg Wilson: How We Got Here. A primer on the creation of money, monopolies, corporations and the works. Less didactic and an easier read is his more recent article, When the Model Is the Harm.
• Cory Doctorow: The world has moved on. Whereby “moved on” means left to entropy, with systems holding entropy back destroy by, well, see above. Relies heavily on Stephen King’s Dark Tower series, making Doctorow’s post the first reference to the gunslinger on this blog since 2014.
• Aidan Walker: Cuck Internet Theory. I was less interested in the meme Walker discusses — having abandoned most social media this is the first time I saw photos of “a cuck chair” in that particular context — than in the phrase he used near the end when he inevitably turned to AI: the permanent underclass. The “permanent” part never sat well with me, because it goes against the entirety of the human history which time and again has shown us that members of “the underclass” are very capable indeed of carrying pitchforks if and when the need arises.

• Sasha Gusev: Thoughts on AI in academia. They are good ones. Extra points for leading me to an article from Sam Kriss in Harper’s Magazine about some magnificently agentic stupid people spending away their youth in San Francisco.
• Ruxandra Teslo: Manufacturing requirements are killing cell and gene therapy. The FDA wants companies to make at least two batches of product at the highest standard of manufacturing before approving it for commercial use. You should know this before starting your clinical program, especially if you have manufacturing that’s expensive, so maybe make two small batches instead of a big one? Just a thought. Separately, none of this would be an issue if there was momentum towards considering cell & gene therapy more of a blood bank/cell processing thing than a commercial drug. But then you couldn’t charge as much, could you?
• Regan Penaluna for Nautilus: Lessons in Chemistry, 19th-Century Style. Frustratingly, it takes Penaluna four paragraphs to mention the full name of Jane Marcet, the woman whose book “Conversations on Chemistry” inspired Michael Faraday — first paragraph mention! — to pursue science. The headline is also too broad: this was 1806, pre-Victorian times and barely 19th century. An extraordinary woman. Also: I want that book.
• Kristen French, also for Nautilus: Solving Feynman’s Formula for Eating Well, Parking Your Car, and Finding a Mate. How Feynman’s scribbles in a Thai restaurant lead to a paper in the Proceedings of the National Academy of Sciences, with mathematical proof of a common-sense inkling: more possible choices and more time should lead to more experimentation in order to discover “the best” of anything.
• Adam Mastroianni: Stop eating Lady Gaga’s Oreos. One of Mastroianni’s best, hinged on one key insight: Americans used to see themselves as temporarily embarrassed millionaires. High fortune now being so out of reach for many that it is simply unimaginable, they now see themselves as temporarily anonymous celebrities instead, which is why we have become more tolerant of celebrities hawking Oreos and less tolerant of billionaires. Also, good confirmation that I did not imagine the period when artists were trying very hard not to be labeled as sellouts.

Repugnant.

Abby Care — the listing is alphabetical so it sits at the top — “empowers families to deliver exceptional care”. More specifically, it “trains family members to become paid caregivers for loved ones with disabilities or special needs” and “provides training and community support to deliver better care at lower cost”.

Mysteriously, it also brags about accepting major health insurance providers. Piecing together the fluffy prose on their website and their simple 3-step process ⊕ [Note: Step 1: Get certified with Abby Care through no-cost training. Step 2: Begin care enrollment (with Abby care support for employment, payroll and administrative coordination… Wait, payroll?) Step 3: Deliver quality care. ] it seems that Abby Care wants to be the Uber of home health aid for people who have a family member in need. The proposition is that, since you are already doing all these things for your loved one, you may as well train to do it even better (great!) but also bill your loved one’s medical insurance for it for the “care” you “deliver” (wait, what?) and let Abby Care take a cut (ick!)

The website is also full of community, whether it’s “family-to-family connection and support”, “navigation of community programs and resources” or a statement that “Abby Care brings families together through shared experiences, practical support, and ongoing connection”. Yes yes, you can make this abomination into a community in the same way you can run dirty tap water through reverse osmosis and add back electrolytes to make it taste like a crisp mountain spring. But only one of those comes free, conditional on 1) it existing and 2) you getting to it; RO is significantly easier to obtain provided you have the electricity to run the machine, money for regularly replacing the remineralization filter, and tolerance for wasting four gallons of water for every one you drink.

Mr. Market has a knack for finding an inherently good thing people do out of altruism, sense of obligation or sheer humanity, then putting a price tag on it, taxing it and adding on a 15% service fee to boot — just look at what happened to Airbnb. The only reason some galaxy-level brain at Sequoia isn’t funding a child care scheme similar to Abby Care is that there is no equivalent in health insurance for the care of children. Otherwise I have no doubt that there would be a platform — it is always a platform — for parents to take care of each other’s progeny in return for some meager returns which the platform owners will garnish, laughing all the way to the Silicon Valley Bank.

The monetization of everyday interactions is not new — it first became salient to me after reading the 2019 book Capitalism, Alone by Branko Milanović, which the Wall Street Journal described as “an implausibly dystopian vision of global capitalism’s future.” I am sure the finance whizzes at the WSJ would not find this entire thing repugnant, but I truly wonder about the prevailing opinion among everyone else.

The 109-year-old (National) Sylvan Theater sits directly across from the Washington Monument on the National Mall. Derelict and seemingly abandoned — the last event was in October 2025 — it may be an even better symbol of America’s semiquincentennial than that monstrosity behind the White House.

Since the Acquired podcast was so heavily recommended by John Gruber and Ben Thompson on Dithering, I thought I would give it a try. Half an hour into an almost four-hour episode about Epic EMR, I am not impressed.

The style is in the uncanny valley between spontaneous and fully scripted, where the two co-hosts simulate a dialogue in the style of NotebookLM. I could actually tolerate that part: “The Rest Is History” podcast has the same shtick and I’ve listened to quite a few episodes. What I can’t stand is sloppiness about facts (ahem), and this is what one of the hosts uttered as an introduction to why medical records have become so important:

The important thing to realize from all this is that the vast majority of patients do not feel the cost of their healthcare directly in the United States. Those costs are so laundered through private insurance companies and Medicare and Medicaid, that most people think about any given health encounter as being paid for by someone else, by a part of some system.

If you’re trying to unpack how did our healthcare become 18% of GDP versus 11% of the UK GDP or a staggering 6% of Singapore’s GDP, albeit at a much smaller scale, why are we 18%? A big thing you have to understand is psychologically every healthcare encounter is that the system is paying for it. I’m paying into the system, the system is paying for it, but what does it cost? What do I actually pay? It’s a big abstraction.

This is, of course, hogwash. Citizen of the UK and Singapore are even further removed from knowing how much their health care costs — Singapore has a mandatory government-funded “base” coverage with voluntary private coverage on top, and the UK of course has the NHS which is funded straight from the budget — so anyone trying to blame the American healthcare disaster on patients, the implication being that they are spending money like drunken sailors because they don’t know what anything costs, is trying to pull wool over your eyes.

I would also push back strongly against the first paragraph. No one — underlined, bold, in all caps NO ONE — in the United States of America things that their health encounter is being paid by someone else, because the deductibles are high, so are the co-pays, the insurance premiums are staring at your from the pay stub, and at the end of each encounter with the “health” “care” “system” comes the Explanation of Benefits. I mean, who is this podcast even for?

Oh.

“Acquired tells the definitive history & strategy of the world’s greatest companies” says the home page, not realizing that there is a difference between history and hagiography. These guys are doing the latter, to much back-patting from the buy, borrow, die class which eats that stuff up. I’ll pass.

Go to openevidence.com and you will see, right under the elegant logo and a free text box prompting you to ask a medical question, an immodest tag line: “America’s Official Medical Knowledge Platform”. The boast sits above an enviable lineup of official partners: The New England Journal of Medicine, Journal of the American Medical Association, National Comprehensive Cancer Network, Cochrane Systematic Reviews. If you were a clinician in need of information these would be the first places to go, ⊕ [Note: Save, perhaps, for a few journals in the JAMA network, and I write this as someone who has published in and reviewed for JAMA. ] but now there is no need because OpenEvidence will do it for you, for free and — unlike those poor community doctors whose practices can’t afford an NEJM subscription — with full access to all those journals.

Their About page is even more effusive. “Our mission is to help doctors save lives and improve patient care.” Great! It goes on:

This year, more than 100 million Americans will be treated by a clinician using OpenEvidence. As a product, OpenEvidence is an AI copilot for doctors that helps them make high-stakes decisions at the point of care. OpenEvidence is the most widely used medical AI among verified U.S. clinicians. To date, we have supported over 200 million AI-powered clinical consultations from U.S. doctors and other frontline clinicians.

In a remarkably short period of time, OpenEvidence has become the default operating system of medical knowledge in the United States.

Underneath lies the Team, laden with Harvard and MIT affiliations, and long list of medical advisors ranging from Mayo, Hopkins and Mass General staff to prominent YouTubers.

It was a rather obvious idea, to create a specialized LLM chatbot which restricts its data sources to medical literature only, so when I first saw OpenEvidence, the way it presented itself (partnership with NEJM and JAMA, MIT affiliation) and the price (free for everyone with an NPI) I was pleasantly surprised that these institutions came together for the common good, to create our generation’s PubMed.

Hardy har har.

Scroll further down and under another immodest headline — “Supported by the Best” — sit the logos of Sequoia Capital, Kleiner Perkins, Blackstone, Andreessen Horowitz, Nvidia, Google Ventures and the like. Not listed on the website because there is no “Investor relations” page — that may spook the clinicians! — is the financial history. Earlier this year it raised $250 million in a Series D round at $12 billion valuation. Just three months before that it raised $200 million at $6 billion valuation. In total, it has received close to $700 million in funding over its four years of existence.

Yes, OpenEvidence, “the default operating system of medical knowledge in the United States” (their words, emphasis included), is a tech startup zipping through the first phase of enshittification, i.e. attracting users with a high-quality offering. I would argue that even the “high-quality offering” is a bit of a crock, but we’ll come back to that shortly. Let’s, for the purposes of this paragraph, go with the premise that the unique thing that OE provides is the “artificial intelligence” portion. Well, from what I understand the company relies on OpenAI, Anthropic and others for the actual compute and if that is the case they are one-step removed from the absolute carnage whose genesis Ed Zitron and others have been diligently chronicling. The default operating system of American medicine is an earnings miss away from the blue screen of death.

I won’t cry for the billionaires involved. I will, however, mourn the opportunity cost of so many smart physicians and programmers on their medical and technical teams spending their time on point-one-percenter enrichment instead of truly building our generation’s PubMed. It would not even require compute! The true value of OE is the curated collection and unrestricted access to peer-reviewed journals, treatment guidelines, and systematic reviews, supplements and all. Let me google all that — or better yet, look it up on Kagi — and I will not care at all for the LLM-generated veneer glued onto man-made knowledge. But good luck having NEJM, JAMA et al. open their vaults without the VC-backed carrot of (I suspect) God knows how many millions of dollars for access rights combined with the FOMO stick that Anthropic and OpenAI’s PR teams have been so diligently whittling.

Trigger warning for an LLM-sounding phrase: the mounds of AI slop added to OE search results aren’t just wasteful, they are dangerous. Back in the Triassic era when shmucks like yours truly were nursing their middle-finger calluses writing progress notes by hand you knew that every part of that note contained useful knowledge. With the electronic medical record mandate — thanks, Obama — much of it became an unreadable mix of computer-generated charts and copypasta; you had to look at the end of the note to find actual human thought, whether it is in the Assessment and Plan or the Attending Addendum section. Well, I can report from the front lines that much of the time even that one meager paragraph has become a copy/paste job carrying with it that distinct LLM waft.

I am not against using LLMs for progress notes — we have been using human scribes for decades to write up the facts of the doctor-patient encounter. But those are costly and your rural primary care physician certainly won’t have one, so why not delegate that work to AI? The assessment and plan, however, are where you infuse those facts with meaning and then act on them, which is the entire purpose of the physician’s job. Writing is thinking and millions of US medical professionals have decided to delegate the one job they have to AI while keeping all the moral and legal responsibility, reverse-centauring themselves willingly and with eyes wide open.

This may seem like a “the food is horrible and the portions are too small” joke — have I not just wrote that the whole thing will soon be dead? If you are a physician who values their brain and doesn’t copy off a clanker why should you care if either start relying on them and then get a rug-pull? Three reasons:

• Expectation-setting: those who copy will need 15 minutes per encounter, then 10, then 5, continuing to ingest slop and regurgitate it over patient notes even as it gets increasingly bad from more and more expensive compute.
• Asbestos exposure: as in, AI is the asbestos we are shoveling into the walls of our society, only the asbestos here is in the form of regurgitated slop we are putting into patient medical records. That, too, will take our descendants some time to dig out, although human life span being what it is it should be less than a whole generation.
• Thinking of the kids: some of my own highest yield learning moments were reading the attending addendum on my note, or the dictation of a particularly skilled specialist’s consult note; will the incoming generations of medical students and residents have the same opportunity?

So if your mission truly was to help doctors save lives and you weren’t a greedy son of a bitch would you not have made a non-profit to achieve that goal? It may not have been as slick as something coming out of Silicon Valley, but it would also not have the risk of blowing up if the financial winds turn and the funding flywheel stops spinning. After all, there have been many attempts to replace the government-funded Medline/PubMed combo, but none of them were that much (if at all) better to justify the cost.