A propos of nothing in particular, a memory came back to me this morning. I was a first year — more precisely, first month — oncology fellow at the National Cancer Institute, and had the dubious honor of having bone marrow transplants as my first rotation. This was back when NCI did not require proof of legal residency to enter the campus, so we had quite a few referrals from all around the country for people who otherwise would never have been able to afford one. These were clinical trials of bone marrow transplants, but the risks of the research procedure — whether to use drug A or drug B, bot approved, to prevent graft versus host disease — were minor compared to the risks of a standard full-on allogeneic transplant, so before you think “but isn’t this undue influence?” let me reassure you that, for the most part, it was not.

Anyway, one of these patients was a young woman with Burkitt lymphoma not responding to any chemotherapy you threw at it. I saw her in clinic early on during the rotation and despite having this rapidly progressing cancer didn’t look all that bad. She had just finished the last round of Hail Mary chemotherapy meant to control the disease before the transplant so had to wait a couple of weeks before being eligible for the trial, and so she went home somewhere in the Midwest to be with her family during this “washout period”.

She did come back, with a portruding belly and a hollowed out face, both of those tells that the lymphoma did not care an iota about any hail marys her doctors threw at it. Her labs, from blood counts to kidney and liver function, looked great, but true enough her PET scan had more areas lighting up than not, lymphoma everywhere.

In most other places this would have prompted a discussion about hospice and end-of-life care, but not at the NIH. She was admitted to the largest research hospital in the world to get some more chemo followed by, let’s hope, the life-saving transplant.

So I got to see her and talk about her at rounds each morning, and each morning that I saw her, belly stil protruding, face still hollow, I’d paint an uggly picture and at first hint then overtly ask, what were we doing here and why wasn’t she already in hospice?

One of those mornings, the inpatient attending who was by the luck of the draw also the primary investigator of the clinical trial she was supposed to be in had enough. All of her organs were functioning. She didn’t have an infection. The cells will be ready in a few days. “What exactly do you think will be the mechanism of her demise?”, he asked, and the phrase struck me as so out of touch that I remembered it to this day. This was a scientist first, maybe a great scientist, asking the question, but a piss-poor doctor.

The point of much of medicine is that we have no clue what the exact mechanism of someone’s demise will be, but we have seen enough and read enough to know that a quick demise was the most likely outcome. There were many things that could have gone wrong at any second: tumor eroding into a large blood vessel causing her to exsanguinate; massive infection taking over after her bone marrow was completely wiped out by our chemotherapy and her lymphoma combined; a large blood clot clogging up her lung’s blood vessels… It was a long list and I wasn’t a fortuneteller, so I shrugged my shoulders and moved on. She died a few weeks after I left the inpatient BMT service.

So anyway, when people ask how exactly the AI bubble will burst, in a way that’s challenging the very idea that it is a bubble that may burst, I remember this patient, shrug, and move on.

The book is a quick read if you are familiar with Doctorow’s other writings, and/or have listened to a few of his interviews. He is nothing if not consistent and, in the case of AI, consistently correct.

Style

You may, if you feel particularly carmudgeonly, argue that this is a book that could have been a blog post. You would be off by only a degree: each chapter does in fact resemble a piece or three from Pluralistic, his decades-old blog. You may notice that each daily article there starts off with an appropriate picture collage of Doctorow’s own making. “Reverse Centaur’s Guide” is his blog post collage. But he is so good at hiding the seams.

Substance

No arguments there. AI of the day, which is to say LLMs, are a real technology with real uses that is overhyped beyond any reason. Unless Anthropic and/or OpenAI do great a general supper-intelligence — which they won’t — we will witness (if we are lucky) or suffer their fall.

There are now material ways in which LLMs have improved my life.

At work, it is mostly by transcribing the first patient visits so that I can focus on listening to the person in front of me rather than scribbling in a notepad or staring at a screen while nodding my head pretending I am paying attention. ⊕ [Note: It is not that you get worse at multitasking with age, it is that you realize you were never particularly good at it so you stop pretending. ] Occassionally, for someone recently discharged and with a million notes, tests, and imaging data in the aftermath of their hospitalization, I may use EPIC’s crude but useful built-in summarization tool. I will even use OpenEvidence in preparation for a visit, but I maintain that free and unrestricted search through NCCN, NEJM and JAMA archives would have yielded the same result, and with fewer linguistics tics.

Personally, I have barely moved from my original use case, which was solving household problems. Having installed Meta’s Muse, sandboxed, locked out of any personal information, I do understand agents have their uses:

• Sorting out children’s school emails from two different institutions and for three separate grades and turning them into something actionable.
• Filtering out automated consulting requests and pre-filling answers on availability and general experience.
• Dealing with the administrative wonders that are part of being a small landlord in DC.

In other words, infrastructure-of-life stuff, the exact opposite of what the big mind of Muse espoused. Plans for self-hosting are in progress.

If your reaction to the above was largely negative, you should read the book. Doctorow makes a much better case than I ever could for why it is not morally abhorent to use this new technology. After all, are you boycotting the interstate system because Hitler championed the first autobahn?

May I propose “BSI”, for Bullshit Intelligence?

Dictated the first draft of this from an Index 01. Integration with Micro.blog isn’t there yet but at some point I might be “writing” blog posts with only my left index finger.

Without having seen this week’s Apple event, I can feel it in my bones that the future of pocket devices is something small that can on demand turn into something big. No, I’m not preordering — for reasons — but surely the matte screen and other crease-hiding trickery will at some point trickle down to a sub-$1,000 inflation-adjusted level.

I can wait.

Alex Tabarrok writes that it doesn’t matter if the workers’ share of GDP shrinks because of AI. As long as the pie is bigger — and our AI oligarchs say it can be as much as 10% bigger each year! — the average worker will have a bigger share in absolute terms if not in relative.

Hogwash. The one who has the bigger slice has the power to lord over the ones with smaller slices so the relative size does in fact matter. Never mind that our sense of wellbeing is itself ties to how we perceive ourselves in the overall community. What Tabarrok proposes is voluntary serfdom. I think not.

• Dan Luu: Ed Zitron’s AI prediction track record. Not great. I have linked to Zitron a few times, to articles that were short enough for me to actually read and understand. Most of them were just too long and/or too angry. Fitting that a critique of Zitron’s writing is just as long, though much more even-keel.
• Lilly Lynch: Sympathy for the Devil? Lindsay Clancy, Mercy and Maternal Filicide in History. The less I know about this case the better, but this was some good context.
• Ernie Smith: Wanted: Some Cheap Computing. Issue No. 1 of Smith’s mini-PC newsletter. I am in the market for both a heavy-duty primary machine and some satellite servers, and thanks to the ramapocalypse the latter — and therefore this newsletter — is much more appealing.
• Derek Sivers: Bangalore India hospital flow. Today I learned Sivers was a fan of “executive health checks”. Yikes! As I wrote in a comment to the article:

The human body is not a car. We don’t know how most of it works. There are a handful of labs you should start getting once you hit 40 (or earlier depending on family history), and a few cancer screenings we know work. Anything else is a needless waste of money at best, and a recipe for an iatrogenic disaster if an incidental finding from a whole-body MRI leads to a wild goose chase, biopsies, surgeries, etc. Not to mention the false sense of security these things can give.

Calling it now: “quietly” is Word of the Year 2026.

What AI sired, mindless zeitgeist reverberators now rear.

Haven’t mentioned it in a while, but my move away from Apple continues.

Pixel 10a purchased, GrapheneOS installed.

Alea iacta est.

Apple rejected an astronomy app from the iOS App Store because “it was astrology”. When the author appealed, Apple doubled down because “We understand that the app includes a live tarot reading feature.” Ridiculous, right?

Well. The author in question is Terry Godier, and while I understand that he has gained quite the following in recent months, I am not a fan. He is unabashedly pro undisclosed AI writing, having conjured — “written” would be inappropriate in this context — a whole essay on large language models being a whole new communication technology. Trigger warning for those sensitive to LLM-ese.

The app, “Dark Hours”, was supposed to be an iOS-native version of this website. It has some truly useful information on the quality of the night sky for stargazing at any given location. It also has the tells of AI generation: too wordy — or overly verbose, if you prefer LLM talk — in some places, too technical in others. Many small digits scattered around the screen. It even manages to fit a this-not-that in what should be a technical explanation.

I have nothing against using LLMs as a coding aide. Dave Weiner sings Claude praises daily in his blog, while being realistic about its limits. Half of the ATP Podcast is an advertisement both paid and unpaid for OpenAI and Anthropic. The creator of Pedometer++, Widgetsmith and many other apps, “Underscore” David Smith, had a good post on his use cases. If you look at their products you could never tell that they were “made by” AI, because they weren’t. If any of them has ever made a fully “vibe-coded” app, they have yet to publish it under their name.

But then if you do fully vibe-code an app, and I am not a programmer so professionals please chime in, can you and do you vet every single line of code? “Live tarot reading” is a weird mistake for a human reviewing an app to make, unless there is a live tarot reading advertisement (or, why not, full functionality) somehow baked into the thousands of lines of code. Stranger things have happened than an app behaving differently depending on the IP address, though they usually try to hide something from the App Store reviewers, not show it to them.

All this to say, the story smells and I’d withhold judgement until we have more information. Unless, of course, it was Apple using automated LLM-based review even in the appeal process, in which case: a plague on all their houses.