Omar Merchant

[Omar Merchant @DrMerch]

been chipping away at https://t.co/fsEWHLIkOZ to fill in gaps in my vocabulary. wish I had a manual like this in medical school tbh. next level would be to add a "choose your adventure" prompts to put knowledge into action

[Omar Merchant @DrMerch]

yall ... buzz is really good. thats the tweet.

[Omar Merchant @DrMerch]

Pardon the French by OP here but “most sources of meaning were already stripped, the job was one of the last ones standing, and now the public feels AI is coming for the brain and robots for the body”
jobs had been the most enduring source of identity in modern society.
For a while it was political identity but political spectrum horseshoes have done a number there too

Rocky roads ahead

[Hugo Amsellem @HugoAmsellem]

SF is breaking spiritually with 3 philosophical crisis at once:

1) talent is existential - infinite options, no idea what's worth building anymore, so they either start smth or join a lab. every week i hear about another founder whose CTO left for anthropic.

2) the public is nihilistic - religion, neighborhood, family, stable couple: most sources of meaning were already stripped, the job was one of the last ones standing, and now the public feels AI is coming for the brain and robots for the body. i live near the openai office in SF, 100s of people demonstrate in front of it regularly.

3) founders are absurdist - building is a commodity, dozens of competitors appear the week you start, every model release kills hundreds of startups or forces a pivot, and the boulder rolls back down. il faut imaginer les founders heureux.

the deeper conundrum i feel: the industrial revolution freed our bodies from labor - we got fat, invented the gym (a synthetic physical activity, like fetching the ball for a dog), then GLP-1 to patch the symptom w/ unknown tail risk on a complex biological system.

the intelligence revolution is freeing our minds from labor and the same playbook is coming - a GLP-1 for the mind (i keep hearing nasal DMT sprays are close). same patch, probably worse tail risk.

and we're still biologically human, so the risk is society splitting into 3 estates: a noblesse replaying la cour du roi, bored and plotting zero-sum games all day (homo leveragus) - a clergé who logs off entirely (homo experiencus) - and a tiers-état dating AIs in second life (homo matrixus). i'm not sure how we "faire société" with that, and as a french i remember the pitchforks in the history books.

underneath all of it, civilization runs on two coordination mechanisms: it coordinates matter through engineering to build technology (we're great here), and it coordinates meaning through storytelling to build culture (we have a problem here). the intelligence revolution pours everything into the first and hollows out the second.

au travail!

[Omar Merchant @DrMerch]

will the submarine be surfacing soon... 😅

[Nawab @WDLD0712]

This photo, and everything and everyone in it, is my politics

[Omar Merchant @DrMerch]

Memory = transmission of knowledge through time
Signaling / speaking = transmission of knowledge through space

🤯

[Omar Merchant @DrMerch]

New venture idea: slop-o-meter to audit yourself and check for delusions of grandeur

[Omar Merchant @DrMerch]

What in the singularity?! Neobank shipping consumer software. I guess block/dorsey was ahead of his time

[rahul @rahulgs]

Every week, the price-intelligence-latency frontier shifts, and we expect this trend to continue

Across 100+ use cases in our product, keeping all up to date with the right model is a challenge -

Either we're losing out on intelligence for the dollars we spend, or we're spending too much money for the intelligence the feature needs

Ramp Router lets you benefit immediately without rewriting your application. We cut our LLM costs by 30%, while also making our features smarter and faster.

We built it for Ramp. Now we’re opening it up to everyone.

get access here: https://t.co/oGnv7GUHsl

[Omar Merchant @DrMerch]

Agree with assessment as outlined by random anon on the internet.

Signed,
You neighborhood primary care physician, MD

[signüll @signulll]

most doctor visits are almost completely useless endeavors now cuz they’re also just googling shit. chatgpt & claude are 1000x better in every dimension if you are even remotely able to problem solve in any meaningful way.

before someone comes after me, i am only talking about front line doctors. e.g. your primary care physician should be an ai for the majority of individuals, there is not even a question about this anymore.

the only real thing keeping these guys in business is pure regulatory.

[Dutch Rojas @DutchRojas]

Is Healthcare a Right or a Rigged System?
A DPC Discussion...

When the New England Journal of Medicine publishes an op-ed arguing that direct primary care is a danger to the “common good,” what they really mean is: too many doctors are opting out of the game.

This episode of The Doctor’s Lounge isn’t just a rebuttal. It’s a war cry. Four practicing physicians dismantle academic hypocrisy, expose the Medicaid industrial complex, and ask the question no one in Washington will:

What happens when the safety net becomes a subsidy machine?

This is not a debate about compassion, it’s about control.

Three Quotes I loved:

“Primary care doctors are getting paid less than plumbers, and somehow they’re the ones being blamed.”

“If Medicaid were truly a safety net, why are insurers profiting like it’s Wall Street?”

“The moment patients control the money, the system collapses—and that’s what terrifies them.”

[Omar Merchant @DrMerch]

This is the most poignant summary of why patients are experiencing frustrations navigating “health systems” I’ve come across

[John Asghar @JahangirAsgha10]

A Reminder for Patients:

The reason you can’t get an appointment…
The reason you don’t have the same physician year after year…
The reason healthcare feels colder, more chaotic, and less personal…
The reason you have less and less choice in your care…

It’s not because your doctor stopped caring.
It’s because insurance companies, large hospital systems, and government policy decided you don’t need choices.

They decided:
•A monopoly makes more money than your autonomy.
•Drugs should cost more—even when they don’t have to.
•Access should be limited—especially if it threatens their margins.
•The physician-patient relationship is secondary to administrative control.

I see this firsthand.
Every Friday, I run a clinic on the Space Coast of Florida.
The most common complaints I hear from my patients there?

– “I can’t get in to see my doctor.”
– “Every time I go, it’s someone new.”
– “It feels like no one really knows me or my history anymore.”

Since Cleveland Clinic of Florida entered the market and bought out most local practices:
– Wait times to see both specialists and primary care have skyrocketed
– Physician turnover is so high, few stay more than a couple years
– Patients are left with less access, fewer options, and a revolving door of providers

They didn’t improve care. They consolidated it.
And you’re the one paying the price.

They’ve redirected resources away from you and your doctor, and into the hands of institutions, executives, and algorithms.

That’s why care feels harder, more frustrating, and less human.

[Dutch Rojas @DutchRojas]

Yes, speak for yourself!

You work at a not for profit that takes in billions and you get paid 5x more on Medicaid than a private practice.

Your job is entirely subsidized by regulatory capture.

For Medicaid patients, BMC receives:

Disproportionate Share Hospital (DSH) payments

Upper Payment Limit (UPL) funds

340B drug pricing margins

Graduate Medical Education (GME) dollars

Indirect Medical Education (IME) bonuses

State waiver payments under MassHealth reforms

Meanwhile:
Independent physicians get barebones Medicaid fee-for-service, often below the cost of delivery.
No bonuses.
No carve-outs.
No federal tailwinds.

Same patient.
Same Medicaid card.

Two very different systems.

Let’s stop pretending academic health systems “carry the burden.”

They’ve built an entire business model around subsidized Medicaid volume, while calling themselves safety nets.

Get rid of these non-profits.

[Dutch Rojas @DutchRojas]

There is, in the United States, a curious tradition of treating medical pricing like state secrets.

One may receive a bill for $112,000 and still be left wondering what exactly was done.

Imagine being mugged in an alley, and when you ask how much they took, they say,
“Speak to your insurance company. If they don’t cover it, we’ll be back.”

It’s not just inefficiency.
It’s theatre.

A Kafkaesque operetta where no one sings in tune, but everyone pays admission.

#healthcare

[Omar Merchant @DrMerch]

- the medication list bloats up, leading to complications, a pill to treat another pill etc). patients are looked at by their individual organs, rather than as a whole.

[Omar Merchant @DrMerch]

The American Healthcare System is Fundamentally Broken - a 🧵
In my first 5 years of independent practice I exclusively practiced in the inpatient setting. Generally this meant, sick patients, many with multiple advanced chronic diseases, care that required hospitalization

[Omar Merchant @DrMerch]

- many specialists are filling the role of primary care, or patients have 5-6 specialists they are seeing regularly. No one is captain of the ship, too many cooks in the kitchen (insert adage of choice). this leads to polypharmacy (prescriptions get added on with no oversight)