After 16 years of successfully avoiding Epic*, tomorrow is the day: my provider** training begins. Let’s see how it compares to Cerner, Allscripts et al.

• Fairly certain text behind the link is partially AI-generated, but the illustrations are good!

** Hate hate hate that term.

Every dickover is infuriating, but the worst ones by far are on the websites I’m already paying to access. Go to hell, Gray Lady; what you’re selling doesn’t need an app.

• Keller, Murray, Ivory & Cabreros for The NYT: The Deadly Rise of Giant Trucks and S.U.V.s. A beautifully-illustrated case for America’s king-sized vehicles being the main culprit for increased pedestrian deaths. The careful reader will remember that this “Big SUV hypothesis” was also highlighted by Brian Potter a while back, though it didn’t explain all of the increase. And of course my conspiracy theory may also be true, although if there are people who said a while back “hey, these big A-pillar will lead to more pedestrian deaths” and then there are more pedestrian deaths, well, there’s a conspiracy theory for you.
• Adam Cifu: Advice for Internship. July already? Seems like my last day of residency was but a few years ago, but now, it’s been a full dozen years as of today. And I’ve given up sharing tips almost as long ago.
• Casey Handmer: In Defense of the Marginal Baby. Handmer presents the case for having more babies, with which I agree wholeheartedly. I do not share his enthusiasm for a contraption some call a “Snoo”, a preposterous subscription-based baby rocker.
• Charlie Stross: The Golden Age Of (sic!) Bond Villains. Stross shares the afterword for a reprint of his book The Jennifer Morgue, which is about a billionaire who wants to unleash a Lovecraftian horror in order to rule the world. It was written in 2009 and yes, some idiot billionaire — probably one from the Dialog crowd — must have confused it for an instruction manual. Anyway, Stross’ “Interview with the Entrepreneur”, the entrepreneur in question being Bond arch-nemesis Ernst Stavro Blofeld, is a thing of beauty.
• Ian Finder: UHF X11. A beautifully pixelated window system built for visionOS and Apple Vision Pro. Due to my newfound aversion to Apple I haven’t touched my own AVP in almost a year. This has persuaded me to pick it up again, for the novelty if nothing else.

• 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.

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.

Back in Pleistocene when I was in grade school and still had dozens of hours per week to spend on PC games and when computing power and storage space were so precious that even quick-save — forget about autosave as the feature was yet to be even a glimmer in game developers’ eyes — were just not a thing, my obsessive tick which I repeated every 10 or so minutes was to stop whichever game I was playing at the time, go to the menu, and save my spot, “just in case”. This is when saving the game carried weight and you could name each time point, all of mine being named just that: “just in case”, or rather, its abbreviated Serbian equivalent “ZSS”. I rarely ever reloaded since these were mostly Sierra and LucasArts-style point-and-click adventures in which it was quite literally impossible to get stuck or make a wrong move, or early RPGs like Lands of Lore which, OK, had its challenging moments, but certainly not enough to warrant 10-min saves.

Fast forward three decades, when my own children have in that regard fallen so far away from the tree that they’ve landed on the gaming Moon [Note: Fallen upward, clearly. There is nothing wrong with this metaphor. Please carry on. ] where the abundance of autosave has destroyed any spot-saving reflex they could have possibly had and with it also any sense of dread for things to come. I was reminded of this stark difference after JTR wrote about his own fears playing Subnautica. There is a link there but it leads to a “Page Not Found” even though the article came through in the RSS feeds and I don’t know if this was a feed-only post or a Micro.blog bug so [Note: Mystery solved, please see @jtr’s comments below. ] I will quote liberally here:

The first time I played, the game had the element of surprise. I remember my first reaper: it came out of nowhere and grabbed my Seamoth like a plaything. I yelped, slammed the Alt+F4 keys, and stomped out of my room as white as the hallway wall I was leaning against, mumbling “oh my god” over and over. Now I know better. I know where they are, I can see them in the distance, and… I’m still scared. But I go ahead anyway. The fear is not pushing me away; it’s teaching me to be prepared. The only thing that’s really scary is fear itself.

See, I never played Subnautica but if I did my playing style would be not much different from JTR’s. Not so for my (nearly) seven-year-old who zips over and across and around reapers and dies and loses some of his supplies and shrugs his just-out-of-toddlerhood shoulders and gets at it again. And if you think that’s because he’s too young to know better you haven’t seen his older sisters play a time challenge level of Astro Bot, a game which severely punishes any hesitation, unnecessary pausing and haphazard jumping.

This is one way of many ways in which the kids are better than their parent, and I put much credit in the autosave abundance!

The power of the Internet is that, under an innocuous title such as Sdcv-quick Update, on a mostly technical blog dedicated to Emacs, one can find a most delightful essay by James Somers — from way back in 2014, the days of still-capitalized Internet — about the power of the old Webster’s Dictionary, how it outshines its modern successors, and how, wonder of wonders, you can download and install Webster’s Revised Unabridged Dictionary (1913 + 1828) onto your computing device of choice. [Note: But not Emacs. That’s where quick-sdcv.el comes in! ]

Somers does not quite reach the heights of David Foster Wallace’s Authority and American Usage but then he also takes only about a fifth of the space to make his point. ⊕ [Note: If these two weren’t enough, “Draft No.4” by John McPhee will do nicely to meet your dictionary essay needs. ] His whole blog makes for great reading, most of it having been written pre-LLMs. This is important: Somers is a professional writer whose most recent articles in The New Yorker and The Atlantic keep glazing AI. If you think I am exaggerating, here are some of the more recent titles: “The Coming Software Apocalypse”, “The Scientific Paper is Obsolete”, “How Will A.I. Learn Next?”, “A Revolution in How Robots Learn”, “The Case That A.I. Is Thinking”… With this kind of coverage, who needs a marketing department?

In the preamble to his Morose thoughts at the Semiquincentennial, @ReaderJohn notes:

I’m on a social medium (I refuse to abuse the plural “media”) with an astonishing number of people, many of them decades younger than me, who manage, without coming across as idiots (au contraire: I’m struck by how many there make me feel unobservant and thick-skulled about what I do observe), to focus on positive, and personal, and local things. Kudos to its designer, who consciously designed it that way (I’m not sure how, except that one never knows how many people follow him or her, and there are no buttons to simply “like” a post).

That last parenthetical is, I believe, exactly the reason why micro.blog turned out the way it did. My first thought was that it filtered out people who liked to see numbers go up — many of them not of the clearest mind — right at the outset. But that is not all there is to it, probably not even the most important part. The intentional lack of statistics cuts the feedback loops which tend to make some people into complete assholes, and every person into an occasional asshole. [Note: Or at the very least an asshole-appearing online presence, but to the exposed person — meaning you, dear reader — there is no difference. ]

Every popularity contest will reward the extremes. This is why I gave up following the Bear Blog Discovery feed. Random posts from to-me unknown authors just popping into my RSS reader [Note: These days a combination of the [Inkwell][4] Android app on my Daylight tablet and my own homebrewed [Inkling for Emacs][5], which is where I’m writing this! ] reminded me too much of Twitter’s algorithms, and even Bubbles — posts from 5,000+ independent blogs, including this one, ranked by timeliness and popularity — favors criticism of AI and tech in general combined with outrage/despondence/resignation towards news of the day/breakage of everyday life/civilizational decline. The only ever Infinite Regress post that ended up on the Bubbles front page fits right in. ⊕ [Note: A kind reader even uploaded it to Hacker News, where it — thankfully! — received just 4 upvotes and no comments. Small mercies. ] It is, in that sense, no different from Reddit: the medium (of voting) is the message.

Incidentally, these Bubbles and Hacker News and Kagi Small Web and indieblog.page and ooh.directory visitors all leave footprints on this here web site’s Tinylytics dashboard, which has become delightfully uninterpretable owing to the influx in the past few months of what I can only assume are digital ghosts from Hong Kong, Singapore, China and Mexico, in that order. An unexpected benefit of LLM crawlers.

There is something about numbers that makes people’s brains stop working. This is common in medicine, where reflexively treating a lab abnormality without thinking an iota about the patient or even about the ground truth — is this number here “real” or is it a blood collection/lab analysis/data entry error? — is a phase most doctors go through and some never leave. Call it video game brain: confusing the hardcoded information of an RPG stat or a FPS health bar with more malleable values we get from physical measurements.

Well, I know enough about myself not to expect an effortless change in behavior. The effort tank being depleted daily by issues more pressing, I avoid having to interpret these numerical tricksters in any way I can. You see, for feedback to be of any use there has to be effort somewhere and by making leaving it effortless (thumbs up or down? how good was our service from 1 to 10? the text field is optional!) we have made interpreting it seemingly straightforward but in fact harder. Did someone “like” a blog post because reading it was a life-changing experience? Slightly more amusing than the cat photo just below? A toilet seat mistap? Or was it herding?

Now think about all those feedback surveys you started filling because the first page was a deceptive 1–10 scale only to abandon it because page 2 had five large fields for free text, all with a mandatory character count. This puts majority of the cognitive effort on the feedback provider; reading it does take more time than glancing at a number, but the receiver can quickly and effortlessly tell whether it is a) from someone whose opinion they care about and b) what the said opinion is.

So yes this is a long-winded way to nudge you towards writing more emails. Or leaving more comments. Or even starting your own blog. More words, fewer numbers, please. And yes, yes, I am aware how silly asking for more words sounds in these, our Days of Slop. But to go back to the blog post that started all this, and then two links deep to a most brilliant text from Sam Kriss: when everyone from your middle manager bosses to Guardian journalists to prize-winning authors and random tech folk debase themselves with AI, the value of the human-written word does in fact go up.

• Kyla Scanlon: Is AI Going to Destroy our Lives or Not? It has been two months since Scanlon last posted so this is a long update that doesn’t cover much more than Ed Zitron recently did, albeit in a — to me, at least — more readable style. The last section, titled “What Do You Do About It”, may be useful to many.
• Reese Richardson: How much of Thermo Fisher’s antibody data has been manipulated? A lot of it, it looks like. I wonder how many poor PhD students and postdocs wasted weeks and months of effort because the antibodies Thermo Fisher Scientific sold weren’t as specific or sensitive as they claimed. Surely as a publicly traded company TFS should have known better. Must have been a rogue employee, or a hundred. Caveat emptor!
• John Siracusa: EV Stupidity Checklist. Twelve physical items that have gotten worse since more cars became electric, with recommendations on how to go back to saner designs. You know, ones that include a rear window
• Brian Philips for The Ringer: The 40 Most Rage-Inducing Problems in Tech. ⊕ [Note: ᔥAlan Jacobs ] A broader list and more tongue-in-cheek, but items 37 through 39 cut deep.

Have a great weekend!