Post-It Note Syndrome: February 4, 2018 Snippets

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This week’s theme: how formal versus informal communication in health care contributes to cost disease and system breakdowns. Plus customer milestones from Wave Accounting and Slack, and some new podcast material.

Last week in Snippets, we took a first look at cost disease in health care: why health care gets continually more expensive, and in particular why American health care stands out as uniquely costly. We took a look at some evidence that suggests that American health care is actually a lot like higher education in an important way: the root of our spending isn’t so much escalating prices for individual services, but rather the volume of them that we consume. (This has been a recurring theme for us: it’s not a price problem, it’s a volume problem.) And finally, we left off with an unsettling question: with technological advances like AI set to transform health care in the next few years, do we really think that the outcome is going to be that we’ll save money by hiring fewer radiologists? Or is it more likely that instead, we’ll consume ten times as many scans?

It’s difficult to articulate the secondary worry behind all of this future consumption, but David Chapman hits the nail right on the head with a recent essay whose title may sound like hyperbole, but content is as enlightening as it is provocative:

Post-Apocalyptic Health Care | David Chapman, Meaningness

In recounting the story of navigating the American health care system on behalf of his mother, David finds his way into a really astute observation with what’s afflicting modern health care systems as we continue to add more tech and more services. The more technology and the more machines and tests and services and people and equipment that get added into a health system, the more likely it is that the formal, systemic way that communication is supposed to occur between all of those thing will break down. However, because health care is an essential service and we can’t simply allow it to fail, we fall back on more primitive ways of getting the job done by any means necessary: informal communication between doctors in the hallways, post-it notes left for the next staff shift, favors called in at overbooked clinics in order to fit in an extra patient; whatever it takes. This is obviously not a good way to run a system: every informal, short-term shortcut taken in order to “just make it work” creates a multiplier amount of follow-up work that must be done somewhere else, by someone else in the system, to compensate. But when the patient is dying and needs urgent help, that’s not the main concern! But it makes the entire system run less effectively in hundreds of little ways that add up and compound. It’s not a failure of the new technology. It’s a weakness of a human system that is operationally restricted by the unique and absolute requirements imposed by the Hippocratic Oath and by medical culture.

David writes: “It’s like one of those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology. Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level. Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism”. But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state Skilled Nursing Facility stay? No one knows.

What do you do when systematicity breaks down? You revert to what I’ve described as the “communal mode” or “choiceless mode”. That is, “pre-modern” or “traditional” ways of being. Working in a medical office is like living in a pre-modern town. It’s all about knowing someone who knows someone who knows someone who can get something done. Several times, I’ve taken my mother to a doctor who said something like, “She needs lymphedema treatment, and the only lymphedema clinic around here is booked months in advance, but I know someone there, and I think I can get her in next week.” Or, “The pathology report on this biopsy is only one sentence, and it’s unsigned. The hospital that faxed it to me doesn’t know who did it. I need details, so I called all the pathologists I know, and none of them admit to writing it, so we are going to need to do a new biopsy.”

That’s not to say that all communication breaks down into the informal: “At the same time, each clinic does have an electronic patient records management system, which does work some of the time. And there are professional relationships with defined roles that operate effectively within the building.” But there’s a certain critical mass that, once reached, is very hard to claw our way out of. Again, there are few specific fingers we can point or guilty parties we can blame, because most of this breakdown is being driven by doctors, nurses and staff acting in the patient’s immediate best interest: after all, which would you rather they do: write that shortcut post-it note for the next doctor, or, you know, not? We might even call this “Post-It Note Syndrome”: so long as the quickest way to help the patient lies outside the formal system of communication, the system will never behave the way it was designed, and costs will resist any effort to control them.

This is where I worry some of our enthusiasm around “consumer-facing health care” won’t actually fix this problem. We talk about consumer-centricity and transparency like it’s this salve for health care and its cost problems; how “Amazon and Two Others” (as the New York Times initially called JP Morgan and Berkshire Hathaway, in a hilarious sign of the times) are going to fix these problems for us with their operational magic. Because if we know one thing about consumers, it’s that we like to consume things. We don’t like being told no. The great promise of consumer-driven health care is that if the customer gets put in the driver’s seat, the medical system will find its way to resolve all of its inefficiencies internally as opposed to foisting them onto patients and their families. That’s a good thing. But it may also lead to a world in which we simply consume an order of magnitude more volume of health care, and the corresponding Post-It Note Syndrome by which we compensate overwhelm any cost savings we otherwise might have achieved.


Environmental precipices:

How warp-speed evolution is changing ecology | Rachael Lallensack, Nature

The real culprit behind snowmelt floods isn’t temperature — it’s dirt | Roni Dengler, Science

A kingdom from dust: how America’s biggest farmer is still dependent on unsustainable water | Mark Araz, California Sunday Magazine

A toxic tour through underground Ohio | Justin Nobel, Longreads

Steve Yegge, the guy who wrote that incredible Google Platforms memo all those years ago, on the opportunity in transportation:

Why I left Google to join Grab | Steve Yegge

Tales of deception:

Markets don’t work like they used to — and people are starting to notice | James Plunkett

The banana trick and other acts of self-checkout thievery | Rene Chun, The Atlantic

Powerless placebos | Scott Alexander, Slate Star Codex

After building new African Union headquarters, China spies on Addis Ababa facility | Amira El Masaiti, Morocco World News

Into space:

A successful SpaceX Falcon Heavy launch would give NASA new options | Loren Grush, The Verge

What would you see as you fell into a black hole? | Ethan Siegel

Narrative stories on progress in AI:

AI didn’t decode the cryptic Voynich manuscript — it just added to the mystery | James Vincent, The Verge

How Amazon rebuilt itself around artificial intelligence | Steven Levy, Backchannel

Other reading from around the Internet:

The art of laser focus | Venkatesh Rao, Ribbonfarm

Led by Apple & Alphabet, tech firms could double their footprint in the Bay Area | Cory Weinberg & Mike Sullivan, The Information

The Google Arts & Culture app and the rise of the ‘coded gaze’ | Adrian Chen, The New Yorker

How bikes will take revenge on cars | Marija Gavrilov, Newco Shift

Playing to our strengths: media in an era where quality, scale and sustainability matter more than ever | Jim Bankoff, Vox

How not to die in America | Molly Osberg, Splinter

And just for fun:

Thanks to machine learning, Nicolas Cage can now be put into any movie in history | Zack Sharf, Indie Wire


In this week’s news and notes from the Social Capital family, a few companies hit some big customer milestones that are worth celebrating:

First of all, congratulations to Wave Accounting for reaching their 3 millionth customer! That’s three million entrepreneurs, business owners and SMBs that use Wave for their invoicing, accounting, payroll, receipts, credit card processing, lending, and much more.

Congratulations to the Wave team on a hard-earned and well-deserved milestone. Here’s to 3 million more!

At the other end of the spectrum, you may remember that last year Slack launched a new product called Enterprise Grid, designed specifically for the world’s largest and most complex companies. One year in, and 150 of these huge companies have made the full transition over to a Slack workplace, helping their employees get their best work done. It’s not just big tech companies like IBM and Oracle, but also media companies (21st Century Fox; Condé Nast); Financial Services (Capital One; Liberty Mutual) and Retail (Target; Overstock) and more. Some high praise to share from Jeff Dow, Chief Information Officer at 21st Century Fox: “Slack has been the hammer that has helped tear down the walls of silos across 21st Century Fox. It has enabled us to position Slack as the operating system of collaboration across 194 countries and 171 offices, pulling us together like nothing else has.” Paul Donnelly, a VP at Oracle, puts it another way: “People told us they would quit if we took away their Slack.” If you hear that, you’re either doing something right, or you’re selling drugs. Let’s hope it stays the former; great work everybody!

And finally, we have some premium content for your ears, straight out of Social Capital HQ.

Venture partner Arjun Sethi went on Jason Calicanis’ Angel Podcast recently, to talk about early-stage investing. Hear about the importance of being candid, taking methodical risks, and the critical importance of rapidly-learning, resilient teams. Listen here.

I also went on the air last week, speaking with Tim Hammerich on The Future of Agriculture podcast to talk about blockchain applications in the farming industry. How I ended up there was a fun story: we’ve been doing a lot of learning and researching about agriculture at Social Capital recently, and Tim’s podcast had been a great resource for me in learning how practices are changing in agriculture from real farmers’ perspectives. Tim had hosted several episodes on the promise of blockchain and other token protocols in agriculture, and I offered to go on to do an episode explaining some of the finer points of where this whole “trust” thing on blockchains really comes from. Tim was happy to host me, and we had a fun time chatting. You can download the episode here.

Have a great week, and congratulations to the Eagles and to Philadelphia for sparing us from another Patriots victory;

Alex & the team from Social Capital