The Sweetest Pitbull

I had crazy week last week.

On Monday, I went to NYC for the day for work, and was overcome by a strange dizzy feeling.  Walls spinning; hard to concentrate; nauseous.  I thought — maybe I’m just dehydrated. I took a rest during the middle of the day; I drank a lot of fluids.  I made it back to Boston that evening — barely — and went straight to bed, assuming all would be clear the next morning.

When I woke up, the walls were still spinning, just as they had been.  I started googling.  Now — it’s important to note that I don’t have a standard health profile — 5 years ago, right after our son was born, I discovered that I had several large blood clots, in my intestines and in my head, and I’ve been seeing hematologists, neurologists, and rheumatologists, and have been on blood thinners, ever since.  As you can imagine, the intersection of “dizziness” and “blood clots” is not a good one. 

So I headed straight to the ER Tuesday morning, and ended up being scanned, tested, and admitted overnight.  Turns out I did not have a stroke, but rather I have Vertigo caused by an enflamed cranial nerve (likely due to a virus of some kind).  Vertigo is a really strange thing: first, it’s amazing how much we take for granted our brain/body’s ability to understand and interact with the space around us; when that stops working, it’s very distressing.  And second, it’s (perhaps even more) amazing how well the brain can adjust, adapt, and re-learn, when certain things stop working the way they had been — I’ve been doing PT to re-train my brain, eyes and ears to understand what’s moving and what’s not moving, and where I am — and it’s been surprisingly effective.

But that’s not the point of this story.  The point of this story is about how much effort, charm, and determination it takes to get effective medical care — even in the best case scenario with excellent health insurance, great hospitals, and top doctors.

One of the toughest things about last week was getting all of the doctors on the same page with one another. I’ve got a PCP, a rheumatologist that I used to see in NYC, a history of cat scans and MRIs (from NYC and Boston), a hematologist in Boston — and now as of last week, a Neurology team in Boston following my case.

All of these doctors — each of whom knows a piece of my story and has expertise to offer — do not have a way to talk to each other, and their method of sharing information is outdated at best.

The result of this situation is a mad scramble.  Trying to get record requests initiated.  Trying to compare new images to old images.  Trying to get the specialists to weigh in with each other or at least communicate at all.  Trying to figure out where the PCP is.  Waiting on hold.  Leaving messages for doctors that don’t get returned.  Being scheduled for new cat scans and MRIs that may or may not be necessary — if only all of the doctors could communicate with one another, and work off of the same set of information.

For instance, the day after I was discharged from the hospital — and we headed to Cape Cod for what remained of our attempted family vacation — the Neurologist in Boston called and said they noticed something new on the cat scan from two days prior — and I needed to come back in for another scan.  That meant a 4 hour drive, finding someone to watch the kids (luckily both sets of grandparents were with us), another night away, and another day worrying about what could be.  And it’s altogether likely that better communication among doctors — and easier use of past records — would have made this unnecessary.

Luckily for me, I have a secret weapon.  My wife.  When it comes to medical issues, she has been through a lot — in particular, a decade of dealing with Chron’s disease and Thyroid Cancer.  She has learned — the hard way — what it takes to get through the confusion, uncertainty, bureaucracy, under-communication and fear of having a complex medical situation.  She know that you not only need to get connected with the right care at the right time, but you have to be a quarterback, pitbull, and snake-charmer at the same time to get things to happen.

In her words, you need to be the sweetest pitbull.  

Never ever go away or let anyone off the hook, while at the same time, get everyone to like you and care about you.

My attitude is a bit different — I try to avoid being a burden, and tend to assume that people will do their jobs correctly if you let them.  I leave messages.

Frannie’s approach is different.  On Thursday when we went back for my additional cat scan, we showed up in person at the Hematology unit and the Neuro unit — unannounced; no appointment.  We tried to make friends with the receptionist (critical).  For a moment, it seemed like she would brush us off, but then she said “well, let me call the head nurse and see if she can come talk to you.”  Bingo.  

The head nurse (an angel if there ever was one) came out and saw us.  Carved out a few minutes to talk.  Mid-sentence, as I was explaining my situation, she ducked out of the room and came back with record requests forms for NYC.  With her other hand, she dialed in the scheduler for the next possible appointment and got me set up. With her other hand, she took down the Neurologist’s information so she could coordinate with him. With her other hand, she had NYPH records department on the phone.  With her other hand, she scribbled down her direct line, her pager number, and the Hematologists cell phone number.  She had a lot of hands and she was using them all at once.  Because we were sitting there.

When we were done I gave her a huge hug and actually cried a little.  The difference between having a person who knows you, sees you, and can move the gears of medicine for you — and a person at the end of a phone line or email — is astounding.

And I would never have gotten there were it not for the sweetest pitbull gnawing and smiling our way in.

I guess the point of this story is that it shows me how broken the medical system is.  Even in the best case, there is such a lack of communication, coordination and information sharing.  Data is everywhere and nowhere.  Decisions are slower and harder to make than they should be.  Expensive diagnostics are over-used.  Every patient needs their own sweet pitbull to help pry the doors open and get the system to pay attention them and care about them.

Thinking about this in terms of apps and data — it showed me, crystal clear, that there’s got to be a better way to do medical collaboration.  What I wanted, throughout all of this, was a simple private chat room for me and my doctors — all of them — that provided easy access to my history of records, diagnostics, and care providers, across locations and hospital networks.  A place that let me — and them — ask questions and get answers, and keep everything in one place that everyone could work from.    Of course, there are untold barriers to this vision: insurance, risk/liability, data security.  But it seems obvious to me that that’s the future we should be shooting for.

In the meantime, we can simply hope to recruit the sweetest pitbulls to have our backs. I know I am super thankful to have mine.

  • Second, this model unbundles the existing financial system into layers run by independent companies. To see the value of this, contrast with the US mobile carriers, who used to own the entire stack. They owned the handsets, the operating systems, the applications running on the phone, and the service. This meant that most of the stack never had anything pushing it to get very good, and there were even incentives to hold it back in order to preserve legacy revenue-generating facilities like SMS. By enabling competition at individual layers of the financial system, each one should improve.

The Open Internet and The Freedom to Innovate

I spent the last two days in meetings with FCC Chairman Tom Wheeler and his staff, discussing their proposed Open Internet rules (aka net neutrality).  Monday’s meeting was with a group of NYC VCs, and Tuesday’s meeting was with group of NYC startup CEOs and GCs.

Coming out of these meetings, and after working on this over the past several months, a few things have become increasingly clear.  Specifically, what we mean when we talk about the “freedom to innovate” and why it’s important for the future of the internet (both infrastructure and applications).

The question that the Chairman opened both meetings with was: how can the FCC achieve the dual goals of “access” and “flexibility”.  ”Access” meaning the ability for websites, startups, apps and content providers to reach end-users (and vice versa), and “flexibility” meaning the ability for internet access providers to expand and improve their networks in new (and potentially unexpected) ways.

Access: innovation without permission (on the network)

Yesterday’s startup meeting led off with each company[1] talking about why the open (non-discriminatory, non-prioritized) internet mattered to them — in particular, why it mattered to them when they were just starting out.

Eli Pariser from Upworthy put it perfectly, when he said: “I’m here because I’ve thought a lot about the tests you have to go through as a startup CEO. And I’m very thankful that one of the tests I *didn’t* have to pass was the Knows How To Negotiate A Complex Deal With A Large Telecommunications Conglomerate Test. I’m not sure many of us could have passed that test in the early days of our companies.” Amen.

Many companies noted how long they had operated before they need to hire a biz dev person or an in-house counsel.  David Karp from Tumblr noted that their GC was hire #37 (this was considered early) and they didn’t hire a biz dev person until the company was 7-1/2 years old.  Chad Dickerson from Etsy noted that their first GC was hire #500.  Erik Martin, GM of reddit noted that they he is their policy person (out of a staff of about 50).  Every company in room was able to reach and serve millions of users and customers without having to negotiate a pay-to-play deal with a carrier first.

The buzzword idea is “innovation without permission” — the ability to launch an app, try out an idea, start writing, start competing with the big boys, start gaining real users, just by hitting enter.  Anyone — a 16-year-old kid with an app or a 75 year-old grandmother with a blog — can simply start.   No need to hire a lawyer, negotiate a deal for access, or (in the worst case) file and litigate a complaint with the FCC.  

Then, as David Pakman put it in the VC meeting, “the users can king-make the apps” (as opposed to the carriers charging, and picking, winners).

This is what brought us the internet we have today, and this is the world I want to live in.

Flexibility: freedom to innovate (in the network)

Regardless of whether we want ISPs to “innovate” in the first place, a central and critical question in the open internet debate is how to stimulate ongoing investment in our internet infrastructure.  To make internet faster, cheaper, and better for everyone.  

This is the contentious issue.  Some argue that open internet rules would remove incentives for investment in infrastructure, by limiting the ways internet access providers are allowed to charge.

In the VC’s meeting on Monday, my colleague Brad said the following (as published in the forthcoming FCC ex parte filing — emphasis mine):

Mr. Burnham pointed out that the relationship between innovation in the network and innovation on the network is more nuanced than often assumed. For example, integrating the network more closely with applications by making the network application-aware may be advantageous from a business perspective, because it allows access providers to control the economics and the innovation at the application layer. Mr. Burnham recalled that when he worked at AT&T, at a time when that company introduced several application aware network architectures in an effort to compete with Internet, the network engineers there were so worried that changes in the network would break applications, that innovation in the network was very rare. At the same time, investment and innovation in and on the Internet was growing exponentially because the Internet’s layered architecture separated the applications from the network and allowed each to evolve independently. He argued that regulatory policy that continues to separate the network and applications layers by requiring ISPs to manage their networks in ways that are application agnostic will promote innovation not limit it.”

In other words, separating the applications layer from the network layer actually stimulates investment in both, by giving both the freedom to innovate.

The Virtuous Cycle

This brings us to a central idea:the “Virtuous Cycle” of innovation and investment:

This theory of innovation and investment — in both the applications layer and the network layer — is the core idea behind the FCC’s 2010 open internet rules.  And, contrary to what many critics argue, this rationale was not overturned in the recent court case vacating the rules.  Rather, the court simply ruled that the FCC could not enforce those rules without reclassifying ISPs as “telecommunications services” under Title II.  From the court’s decision:

"Internet openness, it reasoned, spurs investment and development by edge providers, which leads to increased end-user demand for broadband access, which leads to increased investment in broadband network infrastructure and technologies, which in turn leads to further innovation and development by edge providers." (link)

"[The FCC’s] justification for the specific rules at issue here—that they will preserve and facilitate the "virtuous circle" of innovation that has driven the explosive growth of the Internet—is reasonable and supported by substantial evidence. " (link)

So that’s where I’m at right now.  I believe in the power of innovation without permission.  And I believe that we need to stimulate expansive and ongoing investment in our internet infrastructure.  And I think the best way to do that is to align everyone’s incentives and give everyone the freedom to innovate.


[1] Companies attending the 7/15/14 meeting: BuzzFeed, Codecademy, Dwolla, Etsy, Foursquare, General Assembly, Gilt, Kickstarter, Meetup, Reddit, Spotify, Tumblr, Upworthy, USV, VHX, Vimeo, Warby Parker

  • Democrats are sniffing up the wrong pant leg if they think Millennials are firmly in the “you didn’t build that” coalition and will stand for unlimited spending and overreach by government. By the same token, if conservative Republicans are betting the future on gay-bashing, pot-hating, nativist candidates fond of bombing foreign countries, well, they’re shit out of luck, too.

Paul Sieminski on the Open Internet

Fantastic Letter by Paul Sieminski (GC of Automattic)

Re: Open Internet Remand, GN Docket No. 14-28  

June 30, 2014

Dear [FCC Secretary] Ms. Dortch: I attended a roundtable discussion on June 25 with Chairman Tom Wheeler and other representatives of the startup community in San Francisco. The participants are listed in the ex parte letter by Gigi Sohn, dated June 27. I am writing a separate ex parte to emphasize a few of the points we made. First, the Chairman told us that:

  • he was an entrepreneur and investor, not just a former lobbyist for the cable and wireless phone industries.
  • he agreed with us that the cable and phone companies should not be allowed to create a two-tiered Internet with a fast lane and slow lane.
  • he did not believe that Title II permitted him to ban paid prioritization.
  • he believes it is politically more difficult to rely on Title II.
  • though he believes paid prioritization arrangements are harmful, he also believes that it is politically more difficult to make rules that deem paid prioritization and other forms of discrimination unreasonable, per se.

We think the Chairman should not focus on what’s easiest to do in Washington, DC. Rather, the FCC Chairman should begin with the correct policy, which is keeping access to the Internet open and neutral as it has been historically. Before 2005, Title II regulation applied to DSL and phone networks, ensuring nondiscrimination on such platforms. Since 2005, FCC policy statements, merger conditions, enforcement actions, and other oversight have largely stopped discrimination and prevented the emergence of paid priority arrangements. We call all see the vibrant, open Internet that developed as a result, and the primary goal of any FCC rulemaking should be to preserve this. The only effective way to do so is with anti-discrimination rules, which can only be adopted under Title II.

In 2010, the FCC found that pay-for-priority arrangements would be a “significant departure from historical and current practice.” The FCC also recognized that what made the Internet a platform for innovation and free expression was the fact that it was a level playing field not marked by technical discrimination by ISPs favoring some sites over others. We agree that such discrimination is contrary to what has made the Internet great, and the Chariman’s currently proposed rules don’t do enough to prohibit them. Indeed, the FCC’s proposed rules would authorize discrimination and even exclusive arrangements for priority. While that may be politically expedient, it is terrible economic and civic policy. Indeed, it would be highly disruptive to everyone who relies on neutral access to the Internet.

The FCC should do everything in its power to maintain the openness of the Internet rather than pursuing the short-term politically expedient path.

Sincerely, Paul Sieminski

Joi’s 9 Principles of Open Innovation

I spent the day Tuesday at the Civic Media conference, put on annually by the MIT Center for Civic Media and the Knight Foundation.  In addition to being a gathering of a fabulous community of civic hackers and builders, it’s also where Knight announces the winners of the NewsChallenge grant contest each year (here are this year’s winners, in the category of “strengthening the internet”)

Closing out the conference was Joi Ito, head of the Media Lab (and also on the Knight board).  I always love listening to Joi speak, and reading his writing.  He is like the Yoda of open innovation.  The force is strong in him.

In his remarks, he lays out his 9 principles for guiding the Media Lab into the future, which really double as 9 principles for open innovation. They are:

  • Resilience over strength (I would actually change this to “resilience over rigidity”)
  • Pull over push
  • Risk over safety
  • Systems over objects
  • Compasses over maps
  • Practice over theory
  • Disobedience over compliance
  • Emergence over authority
  • Learning over education

This video is the best example of how I try to think about the world, and how I try to work, as I can think of.  It’s speaks to the USV investment thesis, to the ideas behind Regulation 2.0 (in particular resilience over strength and emergence over authority), and to the impacts that the web is having on every sector of the economy.

Here’s his talk — it’s 27 minutes worth watching, for a pure dose of Joi’s philosophy of innovation and the internet: