The Next Big Thing is You


An optimistic introduction to what could come after the VC funded cycle of disruptions and consolidations.

Various new kinds of software, we are endlessly being told, are the Next Big Thing, just about to disrupt like a volcano of New e-Things that will certainly upend all of the things in the next X years. After you’ve read enough in this genre, it turns into a guessing game: will they put X at 5 years, or 9, or 7? You can usually tell by the adjectives in the first three sentences, as the rhetoric is at best overblown Ciceronian pomp and at worst Ted Talk runoff. I like to fill out a bingo card seeing how many rhetorical and ideological crimes I can identify in a given breathless Medium “article” promoting a new startup, written by someone literally overleveraged in the success of its product offering. Here’s a partial list, in case you want to make up bingo cards of your own:

  • Misappropriated macroeconomic jargon
  • Consequences of disruption and other economic violence naturalized and downplayed via bastardized theories by Darwin or Malthus
  • Milton Friedman-esque swipes at central banks as irredeemable cabals that hate freedom
  • The word “gamechanger
  • Endruns around anti-trust law dressed up as Quantum Leaps for Mankind
  • Any pricepoint under $150/month dismissed as “less than you spend on your coffee every morning”
  • A photo of a “founder” or two standing on a stage at a trade show, preferably wearing a cordless mic
  • Market prolepsis
  • Smarmy appeals to how obviously governments can’t be trusted with the task of regulation, or with “data” itself

Venture capital is the real audience of these missives, and, as Mike Judge’s blunt, Aspie CEO seminally quips on the HBO comedy, Silicon Valley, “The stock is the product.” The winner of this debate tournament is whoever promises the most disruption, since that is what the gamblers came to bet on. As we say in Spanish, “A río revuelto, ganancia de pescadores”—when the waters are choppy, [only] the fisherman comes out ahead. (And no, there are not fisherwomen in this analogy.)

These mammoth disruptions very rarely correspond to giant technical leaps, however; most of them are results of the tiniest of innovations in user experience design, marketing, or convenience engineering. From a computer science point of view, these disruptive apps are apex predators on many levels. They centralize or repackage the data traces left by human experience in a tidy, privatized bureaucracy of monetizable information, but to do so, they stand on the shoulders of data processing giants, mammoth infrastructural investments, decades-long collective refinements funding by private-public partnerships and backroom deals with national-security agencies. In just a few short decades, to the tune of neoliberalism’s mantra (“but who will pay for it, surely not me, or us?”), all of this mammoth infrastructural apparatus was rapidly and irrevocably privatized in both legal substance and public perception. The casino of speculative finance not only wrested away from government any control or even regulatory power over the internet “industry,” but in the process it has also convinced the public that many new, dangerous economic practices and social structures are permanent, natural, and inherent to “the internet age”.

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A Mistaken Approach to Diversity


The walls were entirely bare. Thirty-one oil portraits of medical and scientific leaders that had made the room distinctive were gone. Images of Harvey Cushing, Soma Weiss, George Thorn, Eugene Braunwald — and other historic figures — had been removed.

I’d been to the Bornstein auditorium of Brigham and Women’s Hospital many times during 40 years on the Harvard Medical School faculty and nine years as its dean. But when I arrived in the early morning several weeks ago to lecture to the hospital’s storied department of medicine, I was startled upon entering the familiar venue.

A year earlier, The Boston Globe reported that the portraits would be removed as part of a diversity initiative, but I hadn’t seen the result. What I experienced was not diversity, but sterility.

The room was empty, and I snapped a photo of the bare walls. As the audience assembled, two senior professors greeted me. When I queried them about the missing portraits, both seemed uncomfortable. Loss of the portraits was sad, they said, but looking around to ensure they weren’t overheard, they said discussion was “no longer possible.”

After introduction by the chief resident, I delivered my lecture, the bare walls a constant reminder of the missing portraits. Later that day I tweeted my reaction.

The response to the tweet was mixed. Some praised me for my “bravery” in addressing this, while others suggested I should have been more sensitive to the unwelcoming environment the portraits created for some in the community.

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Warren v. Dinter: Should HMOs and ACOs be Accountable for Malpractice?


Three weeks ago I posted a comment here about a decision by the Minnesota Supreme Court in the case of Warren v. Dinter. In that case, the court held, by a 5-2 margin, that hospitalists (and, therefore, the hospitals they work for) can be sued for malpractice even if they were not in a treatment relationship with the patient. I took the position that that decision was the right one. (If you haven’t read my first article, I urge you to do so to understand the facts of the case.)

The ensuing discussion about my article focused primarily on which, if any, of the three health care professionals involved in the decision not to hospitalize Susan Warren were culpable. The question of whether other parties – the hospital, the chain that owned the hospital, Accountable Care Organizations (ACOs) established by the chain, and insurance companies – should be subject to liability received relatively little attention. Two who did comment explicitly on that issue made it clear they thought even asking about third-party culpability was verboten.

In this sequel to “Why did Susan Warren die?” I want to focus on the question, Shouldn’t third parties who make, veto or influence medical decisions be exposed to malpractice lawsuits? My answer is yes. If the answer is yes, then we must support the Warren v. Dinter decision. Imagine if the Minnesota Supreme Court had taken the opposite position. Imagine that the court decided that injured patients cannot sue third parties unless the employee of the third party (the doctor or nurse) who made the decision in question was in a treatment relationship with the patient. Is it not obvious that such a decision would slam the courthouse doors on all patients injured by employees working for insurance companies, hospitals, hospital-clinic chains, and ACOs who were not treating the patients? 

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