If 2019 was the year I made a concerted effort to start reading whole books again, it was even better as practice for the nightmare of 2020. This year has been nothing but books, video games, cooking, and work.

Once again, I thought it might be fun to share a bit about what I read this year. Last year’s reading list was almost entirely fiction and mostly science fiction, specifically. 2020 was a bit more diverse but I think it also lacked any of the singular pleasures of 2019. Tl;dr my favorite book of 2020 was probably The Sympathizer.

Here’s my 2020 reading list in chronological order with shout outs to those that recommended each book to me:

Nothing to See Here - Kevin Wilson

This was a really fun one. It’s got an absurd premise - a nanny takes care of the neglected twins of a rising political star who has the unfortunate habit of spontaneous combustion - but pairs that with a really sweet heart. It’s pretty fun and an easy read. If you’ve ever done weird babysitting, this one is for you.

Thanks to my sister Liya for getting me this as a Hannukah last year.

Exhalation - Ted Chiang

Last year I read Story of Your Life and Others by Chiang and it was one of my favorites of the year. Exhalation, another collection of short stories, is even better. The titular story (Exhalation - about a scientist discovering the key to human cognition and its eventual end) wasn’t my favorite but through the eight or so stories, but Chiang is always exceptionally imaginative and entertaining. Despite being a sci-fi writer, he never feels particularly bound by any one style, theme, or type - you’re at no risk of boredom or repetition.

The Spy Who Came in From the Cold - John le Carré

This was the year I really got into John le Carré. I don’t know what exactly got me to finally pick him up after hearing the name for so long but at least some credit has to go to The Watch podcast. I am so glad I that I did get to read him before le Carré sadly passed away just a few weeks ago. He was an absolutely iconic author and master of the literary spy novel, both of practitioner (he served in MI6) and chronicler of the Cold War and the slow erosion of British imperial power. If you want to get into le Carré, you may as well start off here. The Spy really gets at the dingy cruelty and pain of the Cold War. It’s also a great introduction to some of the iconic characters (namely George Smiley) who are mainstays of le Carré’s writing.

Tinker Tailor Solider Spy - John le Carré

I liked The Spy so much that I moved straight into Tinker Tailor, undoubtedly his best known, most iconic work. It’s just such a slow burn and such a painstaking portrait of its subjects: the characters and the British bureaucracy. I was introduced to Smiley in The Spy and got to really spend time with him as a person in Tinker Tailor. It was also pretty fun to watch the movie and read the book in sequence together.

The Plot Against America - Phillip Roth

I bought this one the first week of March in preparation for the HBO adaptation and started reading it as a we went into lockdown. Let me tell you, that was a fucking trip and I do not recommend it. Plot Against America is a speculative fiction about a Jewish family in New Jersey in the 1940s as America succumbs to fascism and home-grown Nazism sympathizers. It’s a painfully tense and anxious build up, made more so by its pre-teen POV character just trying to be a kid as his world falls apart. I found it deeply unsettling and didn’t even bother starting the TV show.

Legacy of Spies - John le Carré

The last of my 2020 le Carré kick, Legacy is one of the last books he wrote at 86. Fittingly, it’s a series of short stories told by wizened retirees from the service to newly minted agents ready to launch their careers. It’s something of a capstone on his writing in that you really feel both his age and that of his characters, and that it speaks to the ultimate futility of the Cold War. It’s rich and entertaining - everything he writes is - but it’s also pretty gloomy. Regimes rise and fall. Young people die. Spies betray each other and defect. Ground is gained and lost. To what end? The world keeps spinning.

The Great Influenza - John Barry

The pandemic really blew up my ability to read for a while. I was so anxious I couldn’t really focus. Reading about the 1918 flu helped, in its own way. Obviously we’re living in a different world and we’re dealing with a different pathogen than we were 100 years ago but reading about how humanity made it through (that humanity made it through) certainly brought me some solace. The 1918 pandemic came at a liminal moment in medical history, just as the germ theory of disease and epidemiology were becoming widespread enough to shape possibly the first scientifically grounded public health response to a crisis. Barry does a fantastic job weaving together that medical history with its political counterpart: the first World War and President Wilson’s determination to preserve public morale, even at the cost of public health. Sound familiar?

Three Body Problem - Liu Cixin

I read the full Remembrance of Earth’s Past trilogy this year. Each of the books deserves recognition on their own but before I get there, I want to address the elephant in the room. Cixin is a pretty brilliant science fiction thinker (maybe not the best “writer”) and I really thank all the people who recommended it to me (Dan Khan, Trace Cohen, Charley Ma, and many others). That said, knowing what I know about the author, I can’t really recommend this series to anyone. Cixin is an apologist for the Uyghur genocide happening in China:

When I brought up the mass internment of Muslim Uighurs—around a million are now in reëducation camps in the northwestern province of Xinjiang—he trotted out the familiar arguments of government-controlled media: “Would you rather that they be hacking away at bodies at train stations and schools in terrorist attacks? If anything, the government is helping their economy and trying to lift them out of poverty.” The answer duplicated government propaganda so exactly that I couldn’t help asking Liu if he ever thought he might have been brainwashed. “I know what you are thinking,” he told me with weary clarity. “What about individual liberty and freedom of governance?” He sighed, as if exhausted by a debate going on in his head. “But that’s not what Chinese people care about. For ordinary folks, it’s the cost of health care, real-estate prices, their children’s education. Not democracy.”

Remembrance always at least flirts with being collectivist propaganda and I understand that being an artistic in China might put Cixin in a precarious position with the CCP but this is a bridge too far. This whole series was/is a bit of a phenomenon this year and made quite a mark on me and my wider social circle. Knowing what I know now really casts the series in a much darker light and I am not comfortable with how influential it is/will continue to be.

Dark Forest - Liu Cixin

The Dark Forest theory itself is really compelling and I’d definitely encourage you to read about it. Here’s an article that lays it out.

The Pioneers - David McCullough

I took a quick break from space (and time) exploration to read about the settling of the Ohio territories. This is just a chapter of American history I really didn’t know much about: the birth of the country as told from outside the halls of power in the capital(s). While it’s not the primary focus of the book, you can really see the battle lines of the eventual Civil War being drawn in the western territories as early as the 1790s and the choices around slavery in these territories. Is McCullough a bit rosy in his view of the country? I mean the subtitle is literally “The Heroic Story of the Settlers Who Brought the American Ideal West”… But I took a few days to read this one and felt like I learned something.

Thanks to my grandmother for this book as a birthday gift.

Deaths End - Liu Cixin

Even if I didn’t have my other issues with Cixin, this one is where the series really falls apart anyway. So if you’ve read the first two, you seriously can just skip the finale. Seemingly as the books got more popular, the editing got lighter. Let me tell, it was missed.

Power of The Dog - Don Winslow

For my Sicario fans out there, this one is for you. It’s a super intense crime thriller set across decades at the US-Mexico border and the escalation of the drug war (and the cartels as global powers). Winslow does his homework and paints a picture. Pick this one up in the morning and you’ll be done by dinner. Trust me.

Thanks to Nat and Henry for pushing this one on me.

Destiny of The Republic - Candice Millard

In middle and high school I had a history teacher, Chris Mellon, who absolutely loved President James Garfield. After reading this book, I finally get why. Garfield was a pretty incredible guy and probably could have been an incredible president had he not been shot by a crazy person shortly after taking office. His death was a catalyst for what we now think of as the modern White House, a renewed respect for medical science, and even the invention of the metal detector!

If The Pioneers seemed a bit cutesy at first reading, it definitely helped me enjoy Destiny a few weeks later. Garfield was born in Ohio shortly after the events of The Pioneers and there’s a direct through-line from that story to his own. Moreover, Destiny serves as a snapshot in time medical history of the US that leads directly into The Great Influenza and the 1918 flu. The germ theory of disease and antiseptic theory were just *ahem* germinating at the time of the assassination and Garfield famously could have lived if his doctors had been more willing to trust the latest research on antisepsis.

Dune - Frank Herbert

In a bit of a theme, I picked up Dune so I could get ahead of the movie adaptation. Turns out I had more time to get through it than I initially thought but whatever. I’m definitely very excited for the movie. A new Denis Villeneuve? Yes please. That cast? Incredible. The fucking trailer? No words.

…Anyway, Dune is great and lives up to the hype. It’s a weird fucking book but if you like science fiction and fantasy (and especially if you like Star Wars, Star Gate, and/or Mad Max) this is pretty much required reading. It’s not nearly the slog to get through that I was anticipating. Despite its age, it’s such an influential book that it feels timeless. It feels familiar because Dune basically created the tropes and language for everything that came after.

Golden Gates - Conor Dougherty

Dougherty tells the contemporary of California housing policy through a series of vignettes and mini-profiles of some of it's principal players. The co-option of environmental protectionism by anti-housing homeowners is the most cutting piece of the story here and deserves more than the one chapter it got. In short, new construction is blocked over environmental concerns even though the resulting sprawl and low-density development does far more harm than mixing concrete ever could. But these are big complicated fights and if you care about the future of cities and the planet, you should spend the time on this compact book.

Picked this one up after Dougherty made an appearance on the Slate Money podcast.

The Name of The Wind

This is just an old school fantasy epic. Very D&D. If it’s your thing, you’ll probably like it. If not, you just won’t.

Nat got me to read this one.

Interpreters as Diplomats - Ruth Ailene Roland

I don’t normally read straight up academic books but after reading a section of this during my sophomore year of college, it’s stuck with me and I wanted to revisit it. This is basically a survey history of how interpreters have functioned in cross-cultural diplomacy. The idea of interpreters not just translating diplomatic cables but basically brokering diplomacy was fascinating. They played (and still do to a lesser extent play) a very active rather than passive role in negotiations, trade, etc. The interpreters were basically responsible for filtering information selectively to bring the two sides together in practice, even if they each had totally different understandings of the context and meta-narrative of negotiations. Who was being differential to whom, which side was making concessions, etc. There’s even instances where the same treaty says conflicting things in two different languages - both sides get to believe they got the best of the deal. Even if the particulars of language have literally changed (and the legal review is a bit more robust), that should sound pretty familiar to anyone who makes deals for a living…

Thanks to my professor Jun Hee Cho for adding it to the syllabus.

The Sympathizer - Viet Thanh Nguyen

I can’t recommend this one enough. The titular sympathizer is French-Vietnamese double (or triple or quadruple) agent during and immediately after the Vietnam War who is both good at and compromised in his role because of his ability to see both sides at once. Darkly (seriously, really darkly) funny and touching. The style is really interpretive or impressionistic rather than literally descriptive, which works to just draw you in. It’s just fantastic.

Thanks to Henry, Ganesh, and Hannah for suggesting it.

The Cartel - Don Winslow

This is the follow-up to Power of The Dog but it kind of lost me. The first book managed to just toe the line between literary thriller and pulpy trash. The Cartel did not. It’s fine as a beach read but don’t expect much more than that.

Upcoming/What I’m reading now

I often like to read works of fiction and non-fiction simultaneously, switching off between the two periodically. Right now I’m reading Dark Matter, a collection of short sci-fi stories by black authors, and Epidemics and Society, which is exactly what it sounds like.

Next up, I’m looking forward to getting into (in no particular order):

• Address Book: a history of addresses and city planning

• Kochland: profiling the Koch brothers and their influence in America

• The Fish that Ate the Whale: a biography of the banana king

• Artemis: the latest book from Andy Weir, who wrote The Martian

But I am very, very open to recommendations for what to read next, especially fiction. Please send em over!

Tl;dr - we’re hiring an investor to join our team and you should apply.

Last summer I wrote a post called Don’t work in venture capital. It’s probably the most widely read/popular thing I’ve written on substack and among the most widely read/popular things I’ve put on the internet at all (it’s a low bar but still). 18 months later I still get people hitting me up about it and it still drives the bulk of new subscribers to 99% Derisible.

I suspect that that’s less to do with me specifically and more to do with the fact that venture has a certain arcane mystique. For better or for worse (usually for worse), everyone wants a piece but few people understand what it really means. Pulling back the curtain to talk some shit seems to have struck a nerve.

Now we (my firm, Tusk Ventures) are hiring an investor to join our team. You can check out the full job description here and the application here. But before anyone calls me a hypocrite or tries to score an easy dunk, I want to pull the curtain back again and explain why this opportunity is genuinely different. Even if you shouldn’t work in venture, you should work with me.

Go back and read it in full but, as a refresher, I laid out three basic points for why you shouldn’t (try to) work in venture in the original post:

1. It’s very hard to get a job in venture

2. Most of the jobs are not good

3. You won’t make as much money as you think you will

1) This is a straightforward process

We are hiring openly. There is a straightforward application. The target profile is clearly defined. There shouldn’t be any guesswork.

There is no requirement for schmoozing and networking to get ahead of a process. There is a link to an application that shouldn’t take more than 30 minutes to fill out. I have no interest in wasting your time because the time it takes to read applications and screen applicants is my time.

That doesn’t mean you are likely to get hired (hopefully we’ll have tons and tons of great people apply) but it does mean you’re on an even playing field with everyone else.

2) This is a good job

We’re looking to hire someone to fill urgent needs for real work. We’re a small team, which means that while there’s more scut work to go around (for everyone) there’s also far fewer barriers to making a real impact and rising with the firm. We’re just not an old or big enough fund to have super well-defined roles and process. You get to have a hand in driving that by showing up and doing the work. There’s no swim lanes but the ones you define for yourself. And if you can do that, why would we want to let you move on?

My own career here is the best proof that I can offer. I started as an intern and stuck around because I contributed and had great mentorship. Now I’m a Principal and I have no interest in pulling up the ladder behind myself.

This is exactly the type of job I said you should go for if you’re going to go into venture:

IF you are going to work in venture, try to optimize for partner/fund rather than generic “venture capital.” As I’ve said, most jobs and funds are bad. The biggest brand name funds are functionally impossible to get hired at and working there is unlikely to be any better than what I’ve described above. I’d suggest going to a new fund where you stand a better shot at having upward mobility, economic upside (carry), and the ability to drive outcomes.

3) We’re doing well

VCs don’t generally get the cash comp you think they might. The real money is in the upside but most funds just don’t produce all that much. Venture capital is famous for following power laws whereby a very small fraction of investments (and by extension a small fraction of funds) produce most of the profits for the whole asset class. The average investor lags the public markets.

That’s one of the reasons funds almost never open up their books and talk about their numbers publicly. We did.

So what now

Not everyone is going to be a good fit for this job. Not everyone is going to get an interview. But everyone is going to get honest consideration and a fair shake. And whoever we do hire will have our commitment to create a positive, encouraging environment where you can really grow into yourself as an investor.

If you think you’re interested in the role, apply. If you know someone who might be, send this to them.

I wrote that I got so lucky in so many ways and that my experience is non-replicable that it doesn’t bear explanation. I am offering a chance to replicate it. I may be wrong about everything I’ve laid out but I’ve got skin in the game (in fact I’ve got my entire body in the game) backing it up.

What is OnlyFans?

It’s a song. It’s a meme. It’s an endless font of cultural critique. It’s a subscription porn site that is mechanically best likened to an online strip club. It’s an internet juggernaut at the vanguard of sex, work, and sex work. It’s worth understanding better than you do right now.

Ostensibly, OnlyFans is a platform for creative types to post content online and charge fans directly for access in the form of subscription fees, tips, and pay per view extras. In its marketing, OnlyFans never explicitly mentions NSFW content; its website is plastered with information from/for  musicians and artists. But we know better. 

It’s a porn site with novel mechanics. The focus on direct monetization from subscriptions and upsells is a major departure from the “tube sites” that came to dominate internet porn over the last decade. OnlyFans has collapsed the barrier between amateur and professional. By moving from ad-based revenue sharing models (which more realistically turn into production for exposure with monetization elsewhere) to subcription, OnlyFans has turned porn “stars” into influencers. Users aren’t buying or subscribing to content; they’re subscribing to a person who in turn is responsible for sourcing their own demand and managing their own production.

In some respects, this is kind of the platonic ideal for sex work. Sex workers can earn money safely from their homes away from violence and the police. While OnlyFans takes a 20% cut of gross earnings, it’s a far cry from a pimp.

But whatever you think of online sex work - and we can certainly talk about the negatives - the business is working. Piecing together some information put out in May and April of this year, OnlyFans is almost certainly a billion dollar company. At least. It’s bigger than Playboy. It’s bigger than Patreon. 

But if big numbers aren’t enough to get you to care, don’t fret.

If Porn is ur-internet, influencers are a close second. At the intersection of those two, OnlyFans is the most internet of the most internet. It best embodies the liberating commercial spirit (serving the full spectrum of human desire without prejudice) but also its worst tendencies (the bulk of the earnings go to the small pool at the top).

Beyond the commercial disruption of traditional porn and sex work - a disruption COVID has only since accelerated - OnlyFans represents a shift or convergence between technology and sexuality. It’s sex work native to the contemporary internet.

In the 1950s, sociologists coined the term “parasocial” relationships to describe the feeling of intimacy between certain types of broadcasters and their audiences. The man on the TV is talking to thousands or even millions of people, but I feel like he’s talking to me. I feel close to him because of that. It’s a phenomenon that has become so ubiquitous as to be unnoticeable as our media and media consumption has become both more intimate (the media is richer and we consume it alone) and incessant (the average American consumes 12 hours of media a day). 

We’re all familiar with it even if we don’t have a name for it. Think of the podcaster you listen to for banter or the YouTuber who opens with “hey guys, thanks for listening”.

From the New York Times: 

Parasocial relationships are, by definition, one-sided, but like normal friendships, they can deepen over time, enriched by the frequent and dependable appearance of the charming persona on the television set. Podcasts, with their own unique set of formal quirks, are perhaps even better poised to foment this kind of bond. An ideal complement to multitasking, the podcast is ingrained in daily household chores, the morning commute, the bedtime routine. A two-way conversation can be taxing. Podcasts allow us to get to know someone else without all the stress of making ourselves known. 

OnlyFans is parasocial by design. Unlike the tube sites which got their start hosting pirated versions of studio produced porn for 1:many broadcasting, OnlyFans productizes and prioritizes intimacy and feedback. There are whole online classes for OnlyFans creators to learn about managing that because that ultimately is the business. The convergence of sex work and confessional-style social media influencers shouldn’t surprise us. After all, modern influencer parasocial relationships are a form of emotional labor akin to sex work any way.

OnlyFans is at the forefront of a new online sexual revolution. It stands head and shoulder above the rest of the “creator economy.” It’s a testament to how puritanical ideas about sex and sexuality bias and limit our thinking about what matters. It’s a business to watch and understand because it’s at the bleeding edge of the consumer internet and human sexuality.

I've been thinking a lot about and wanted to share in full something I wrote in September 2017 - before 99D found it’s current home on Substack.

That blog is no longer publicly accessible so some of the links don’t work anymore and I’m too lazy to deal with that. Sue me.

I’m sharing it again in part because it now seems quaint but also (hopefully) prescient, at least insofar as I was thinking about the the blurring of “work” and “life” in our self-conception and actualization. We’ve never had a good or healthy conception of “balance” but anything we had seems like heaven compared to the purgatory of working from our kitchens forever…

I was also moved to revisit this after reading Jomayra Harrera’s fantastic essay on The Empowered Economy, which provides some ideas for how the “market self” (in my words) can bolster the cause of fulfillment, flourishing, and non-market social participation. I highly recommend you check that out.

Back to Work!

Summer is over and the Fall grind begins, making this a good time to continue some thinking about the nature of work and our working lives. I’ve written before about the conflicts and idiosyncrasies between work and life, and the shortcomings of the putative work/life balance. “But First, Let Me Apologize,” the argument that the two are not separate and the zero-sum-game of “balance” is inadequate to describe the complex nature of our selves in and outside of work. I wrote:

If your work and life are separate, and you are separate within them, them then when and where are you yourself? And with whom? Given how much more time we spend at our jobs than we do anywhere else, there’s a reasonable case that who we are at work is who really are. Left to its own devices, the work self will overrun the supposedly separate and true self. (It’s all very Dr. Jekyll and Mr. Hyde). Where once hours and working locations were regular and fixed, the internet has eroded clearly delineated borders between what/when/where is and is not work. I emphasized mutual permeability over simple “balance” because it is holistic compatibility, not the mere allocation of time, that really matters. 

Rather than balance, mix is a better term to describe the optimal relationship. In “Status Update” I wrote about the consequences of letting work become the core of an identity:

Today, we pride ourselves on always being busy, always working longer hours, always running a sleep deficit. The people who work regular hours or don’t work at all? Lazy and worthless! In a near future where a larger and larger portion of labor has been automated away, just having a job will be a sign that you are a “big brain.” Work and work-related stress have become indelible markers of status and success. We love to trade horror stories of not having a personal life. It’s a badge of honor, signifying that we’re important and our skills are in demand. This is completely toxic.

A culture prizing work above everything else isolates us from one another. It strips the richness out of life and distorts our perception of personal (not financial) worth. As US Surgeon General Vivek Murthy said, the most prevalent health issue in the country is not cancer or heart disease or obesity. It is isolation. We find meaning and divine our place in the world through our work, at any cost to ourselves. We’ve so deeply internalized these problems as normal that even admitting them is tantamount to failure, admitting that you’re a loser. Socializing has been socialized out of us.

This is not an isolated phenomenon. The increasing primacy of work over every other aspect of our lives is one part of a much larger, longer, and deeper shift in the basic organizing principles of our society: the subsumption of our non-market lives/selves by our market lives/selves. Not only have the parts of lives/selves participating in commerce and the market taken over a greater share of the whole, commerce and the market itself have increasingly encroached on all aspects of our lives and turned them into commercial rather than social endeavors. 

It’s important to add some historical context here. First, the concept of a work self and a life self is a relatively recent invention. It didn’t really exist in the western world before the wide adoption of wage labor, which only began to become the dominant form of labor (excepting slavery) in the US in the early 19th century. And then the two selves were mostly understood with respect to slavery, industrialism, and the decline in artisanship - a trade that was a personal identity.

In The Half Has Never Been Told, Eric Foner juxtaposes the simultaneous advents of wage labor and slavery. He cites the widespread acceptance of wage labor as an essential outgrowth of and development in the expansion of a capitalist market system. There was a marked disdain for wage labor, which was popularly viewed as a form of “dependence.” Moralizing slave owners went so far as to portray slavery as a kinder institution than “wage slavery,” – working for a paycheck. So the idea of a profession separate from the core identity of a person is a new one. It should be obvious why. It requires a sufficiently productive and industrialized society, one which has accounted for or begun to account for, the lower portions of Maslow’s Hierarchy of Needs to begin to debate the nature of the self in any meaningful way.

Second, it’s a myth that the market and non-market aspects of a person were ever fully divided. Nor were there ever was fully market or fully non-market transactions; the two realms always bleed into one another and always have. In Commerce Before Capitalism, historian Martha Howell chronicles how since the 13th century and before the dawn of anything remotely recognizable to us as a market system in the West, social/non-market institutions and relationships (the church, country fairs, gift exchange) laid the groundwork for commerce and modern capitalism. 

The shape has changed - a public ledger of church donations became a rotary club became a networking happy hour became a personal brand - but the idea stayed the same. Business is and always was personal.

I do not mean to brush aside the significance of the changes being wrought. Though the encroachment of the market sphere is not new, we are nevertheless experiencing a tremendous change as the market system is voraciously incorporating and taking over non-market areas of our lives and selves. (With respect to traditionally non-market transactions previously governed over by/transacted with the state, this is what people call neoliberalism - at least when they use the term correctly, which they mostly don’t). This shift in our social and relational norms is not unrelated to Amazon and cities, dating apps, social networks, etc. I wrote about eCommerce:

Going to the grocery store or the downtown shopping center or the farmers market isn’t just a market experience; it is the quintessential urban experience. According to Laura Seidman, an energy efficiency consultant who also teaches at the University of San Francisco, “The downfall of humanity is the invention of the refrigerator. When I was living in Brooklyn, the infrastructure existed from the earlier days, and on my way home I would pass a green grocer, a fruit seller, a fishmonger, the bagel place, the pizza place. That would get you out in the community.” (Link) When you don’t have to go to the store for bread - and in doing so interact with people, run into acquaintances, see other modes of life and ways of being - you’re functionally not living in a city any more. Just a more densely packed suburb.

So as I said at top, the changing dynamics of work are emblematic of the larger trend: the commodification of non-market areas of life. When the mixed market and non-market transactions (like buying bread from a local grocery) become pushed further and further towards being purely market transactions, we gain new efficiency and productivity but we do risk losing something.

Telemedicine in some form has existed for decades. The basic premise is fairly intuitive - “I conduct lots of business remotely, why not healthcare?” Despite that, the adoption rate has remained persistently low until very recently and it is largely only used for primary care.

Historically, one barrier to widespread adoption was the lack of reimbursement parity. Insurers would often pay less for remote care on the basis that it cost less to deliver (I’m not paying for an office you don’t need for this visit). Unsurprisingly, providers responded to that incentive and largely avoided telemedicine. Laws requiring “reimbursement parity” have been passed in a growing number of states over the past decade, providing a major catalyst for telemedicine. There’s money it in now.

Concurrently, the ACA pushed up deductibles such that lots of routine care would likely be paid for out of pocket, especially for the younger people who more often go for high deductible plans. If people are paying for care themselves, they start acting like consumers and want to be treated as such. Cost, convenience, and user experience matter more if care is paid for out of pocket and telemedicine fits nicely with that.

Suddenly the pandemic is blowing that up even more and providers are scrambling to move their practices to telemedicine-first or telemedicine-only to provide care while maintaining social distancing. Telemedicine can help keep them and their patients safer than in-person care.

Insurance set the stage and COVID created the urgency.

Telemedicine 1.0: optimizing patients

The first, simplest phase of telemedicine largely address problems faced by patients. Getting to a doctor is inconvenient under the best of circumstances and most people aren’t in the best of circumstances. If you live in a dense city and can schedule an appointment, you might reasonably travel 20 minutes each way, hang out in a waiting room for 40 minutes, and sit in an exam room for 20 minutes all for a 15 minute visit with a doctor.

You’ve spent over an hour and a half for a 15 minute visit. That means the total time efficiency of the visit is just a measly 15%. And the real averages are almost all much worse on each of those underlying estimates.

Moving that visit to a phone call means spending less time getting care overall. You could pretty reasonably get to 75% efficiency even if the care you receive is itself unchanged.

The first known telemedicine visit of this type occurred in 1879. The standard operating procedure basically hasn’t changed since then. This is what our health system is rushing to adopt as we try to cope with the pandemic. Other than the phone, the doctor is not using any tools differently than she otherwise would have. The direct cost to her practice is functionally unchanged.

Telemedicine 2.0: optimizing providers

Starting in the 1990s, the internet offered the chance for “store and forward” telemedicine. Store and forward, as the name implies, means information is recorded (stored) and sent (forwarded) to a doctor who then reviews it later. The doctor-patient interaction is “asynchronous” (not at the same time) versus a phone or video call which is synchronous.

Asynchronous is only just now starting taking off, in no small part because of recent changes allowing doctor patient relationships to be established over store and forward (asynchronous) mediums.

This creates opportunities to add more technology to the administration of healthcare, not just the delivery mechanism. Parts of the patient journey like intake forms can be productized without the need for large administrative staffs.  Scheduling can largely be obviated for much of routine care if patients and doctors can message asynchronously. If communication is tied directly to medical records systems, charting can be (semi-) automated and data can be originated in structured, machine-readable formats. 

Mixing synchronous and asynchronous communications can help practices better triage and allow providers to spend more time with more acute patients. That also means enabling them to spend less time doing the things they hate doing (charting, admin, etc.), the biggest factor in provider burnout. 

In all, telemedicine 2.0 takes much fuller advantage of the technology at its disposal. It is healthcare built for telemedicine with the effect of scaling doctors, rather than just trying to port in-person care onto a new medium to make it more convenient for patients. That in turns means making healthcare dramatically more available and affordable.

Telemedicine 3.0: what comes next?

Everything described thus far represents clear advantages to patients and providers but comes with very obvious limitations in both the scope (what can you treat this way) and the benefits (why would you bother). No, we’re never going to eliminate all in-person care nor should we even want to. But even as telemedicine 2.0 makes healthcare more available by optimizing throughput, it still does not fully realize the vision of digital-first healthcare.

That is, the 2.0 scheme is still digitizing and modifying analog practices rather than building digital health tabula rasa and with an eye to the newly possible.

The long term opportunity for telemedicine is not to ignore its limitations (home surgery by an on-demand robot!) or pump vaporware (AI for fully autonomous primary care!) but to provide substantively better outcomes and experiences where it can by doing things that in-person care cannot.

That means taking full (fuller?) advantage of connectivity to do things like passive monitoring to track integrated health and lifestyle data. It means continuous patient monitoring and longitudinal data for both better patient experiences and easier, faster clinical trials. It means unlocking whole new modalities for care delivery and coordination build on top of interoperable medical records (eventually). Imagine all that health data from all those different sources and providers coming together into integrated medical records hubs that can surface conditions or direct patients to care proactively. Missing out on the opportunity to find unexpected issues through more casual patient interactions is a legitimate criticism of telemedicine and will always be part of any sober cost benefit analysis.

It means building adherence and retention directly into patient-facing products and provider-facing tools. It means putting even more process automation behind and products in front of providers to scale knowledge and expertise. It means rather than bolting telemedicine onto a physical world practice, going the other way around to build digital-first full service practices. Imagine starting a patient-provider relationship online and directing a patient to in person care only when necessary and where remote care isn’t enough.

What will all this mean for the health systems’ lock in and pricing power? How will it change the physical and operational needs of providers, and in turn the organization of provider groups? How does the slow shift towards value-based care affect (or even effect) this and vice versa? How will we measure the impacts on individual health? On population health? There is certainly more that we don’t know than what we do.

Whatever digital health 3.0 will look like, it seems clear that that timeline has just gotten pulled forward. It’s happening.

Huge shout out and thank you to Nikhil Krishnan for his excellent post detailing the new HC infrastructure and for giving feedback on this post.  If you’re interested in this kind of thing, go subscribe to his newsletter Out Of Pocket.