Amazon Can Still Surprise Me

It’s Cyber Monday, and you’ve probably been shopping this weekend. In-stores sales on Black Friday rose 2.2% this year, whereas online sakes rose almost 8%, to $9.8b – over half of which was via mobile shopping.  Cyber Monday, though, is expected to outpace Black Friday’s online shopping, with an estimated $12b, 5.4% higher than last year. 

Lest we forget, Amazon’s Prime Day is even bigger than either Cyber Monday or Black Friday.  

Credit: Amazon

All that shopping means lots of deliveries, and here’s where I got a surprise: according to a Wall Street Journal analysis, Amazon is now the leading (private) delivery service.  The analysis found that Amazon has already shipped some 4.8 billion packages door-to-door, and expects to finish the year with some 5.9b.  UPS is expected to have some 5.3b, while FedEx is close to 3b – and – unlike Amazon’s numbers -- both include deliveries where the U.S. Postal Service actually does the “last mile delivery.” 

Just a few years ago, WSJ reminds us, the idea that Amazon would deliver the most packages was considered “fantastical” by its competitors.  “In all likelihood, the primary deliverers of e-commerce shipments for the foreseeable future will be UPS, the U.S. Postal Service and FedEx,” the then-CEO of Fed Ex said at the time. That quote didn’t age well.

Amazon’s growth is attributed in part to its contractor delivery program, whose 200,000 drivers (usually) wear Amazon uniforms and drive Amazon-branded vehicles, although they don’t actually work for Amazon, and a pandemic-driven doubling of its logistics network.  WSJ reports: “Amazon has moved to regionalize its logistics network to reduce how far packages travel across the U.S. in an effort to get products to customers faster and improve profitability.”

It worked.

WSJ calculations from company documents. Credit: WSJ

But I shouldn’t be surprised.  Amazon usually gets good at what it tries. Take cloud computing.  Amazon Web Services (AWS) in its early years was considered something of a capital sink, but now not only is by far the market leader, with 32% market share (versus Azure’s 22%) but also generates close to 70% of Amazon’s profits. 

Prime, Amazon’s subscription service, now has some 200 million subscribers worldwide, some 167 million are in the U.S. Seventy-one percent of Amazon shoppers are Prime members, and its fees account for over 50% of all U.S. paid retail membership fees (Costco trails at under 10%). There’s some self-selection involved, but Prime members spend about three times as much on Amazon as nonprime members.

The world’s biggest online retailer.  The biggest U.S. delivery service. The world’s biggest cloud computing service. The world’s second largest subscription service (watch out Netflix!).  It’s “only” the fifth largest company in the world by market capitalization, but don’t bet against it. 

I must admit, I’ve been a bit of a skeptic when it comes to Amazon’s interest in healthcare.  I first wrote about them almost ten years ago, and over those years Amazon has continued to put its feet further into healthcare’s muddy waters.

For example, it bought online pharmacy Pillpack in 2018. “PillPack’s visionary team has a combination of deep pharmacy experience and a focus on technology,” said Jeff Wilke, Amazon CEO Worldwide Consumer. “PillPack is meaningfully improving its customers’ lives, and we want to help them continue making it easy for people to save time, simplify their lives, and feel healthier. We’re excited to see what we can do together on behalf of customers over time.”

PillPack still exists as an Amazon service, but has broadened into Amazon Pharmacy. PillPack focuses more on people with chronic conditions who like the prepacked pills, while Pharmacy offers home delivery to other customers.  At its introduction, Doug Herrington, Senior Vice President of North American Consumer at Amazon, said: “PillPack has provided exceptional pharmacy service for individuals with chronic health conditions for over six years. Now, we’re expanding our pharmacy offering to Amazon.com, which will help more customers save time, save money, simplify their lives, and feel healthier.”

Amazon Pharmacy has since introduced RxPass, a $5/month subscription service for many common generic drugs, but it still hasn’t cracked the top ten U.S. pharmacies, so there’s work to be done. One pharmacy analyst writes: “Perhaps one day Amazon will be a true disrupter.  For now, Amazon is choosing to join the drug channel not fundamentally change it.”

PillPack’s co-founders have recently left.    

Earlier this year, after all the fumbling around with Haven and Amazon Care, Amazon bought One Medical. “We're on a mission to make it dramatically easier for people to find, choose, afford, and engage with the services, products, and professionals they need to get and stay healthy, and coming together with One Medical is a big step on that journey,” said Neil Lindsay, senior vice president of Amazon Health Services.

Credit: Amazon

Then this month Amazon sought to entice Prime members to join One Medical by offering membership for $9/month, or $99 per year.  "When it is easier for people to get the care they need, they engage more in their health, and realize better health outcomes,” said Mr. Lindsay. “That’s why we are bringing One Medical’s exceptional experience to Prime members—it’s health care that makes it dramatically easier to get and stay healthy.”

Of course, One Medical is only in 25 metro markets, with some 200 doctors office, and it doesn’t contract with every insurance plan. Plus, One Medical CEO Amir Dan Rubin is already on his way out of the door. Scaling will not be easy.

Amazon’s success with its healthcare ventures is hard to tell.  HT Tech reports that monthly active users of the One Medical app are up 16% since the acquisition, and that Amazon claims Amazon Pharmacy doubled its active customers from 2022 to 2023. Still, Lisa Phillips, an analyst with Insider Intelligence, scoffed: “It really hasn’t made a big dent. I don’t think anybody is scared of it anymore.”

Maybe. Healthcare is hard, and usually confounds outsiders who aren’t familiar with its byzantine structures.  But I look at it this way: Amazon has been delivering its own packages for less than 10 years, and now it is bigger than UPS and FedEx.  That’s not nothing. So for the first time I’m starting to think that maybe Amazon can make its mark in healthcare. 

Amazon the biggest healthcare company in ten years?  Don’t bet against it.

(We Don't) Trust the Science

I know the A.I. community is eagerly waiting for me to weigh in on the Sam Altman/OpenAI dramedy (🙄), but I’m not convinced this isn’t all a ploy by ChatGPT, so I’m staying away from it.  A.I. may, indeed, be an existential issue for our age, but it’s one of many such issues that I fear we’re not, as a society, going to be equipped to handle.

We like using the results of science, but not learning it. Credit: Bing Image Creator

Last week the Pew Research Center issued an alarming report Americans’ Trust in Scientists, Positive Views of Science Continue to Decline. Now, a glass half-full kind of person might look at it and say – no, it’s good news!  Fifty-seven percent of Americans agree science has a mostly positive impact on society, and 73% have a great deal or a fair amount in confidence in scientists to act in the public’s best interests.  For medical scientists it was 77%. Only the military (74%) also scored above 70%. That’s good news, right?

The glass half-empty person would point to the downward trend in just the past few years: at the beginning of the pandemic (April 2020) the respective percentages were 87% (scientists), 89% (Medical scientists), and 83% military.  The faith in them has continued to drop since.  Things are trending in the wrong direction, quickly.

If the glass was half full, it’s spilling now.

About a third (34%) of the public thinks that the impact of science on society has had an equally positive and negative impact, while 8% think science has had a mostly negative impact. Again, the trend has been negative since the pandemic; the 57% who think science has a positive impact was 73% in January 2019. That’s alarming.

The skepticism about scientists and the value of science has increased generally, but is more pronounced among Republicans and those without a college degree.  E.g., only 61% of Republicans have a fair/great amount of confidence in scientists, versus 85% in April 2020 and versus 86% of Democrats now.  Fewer than half (47%) of Republicans think science has had a mostly positive impact on society, versus 70% on January 2019.

In the supposed most developed country in the world, thirty-nine percent of Americans think the U.S. is losing ground in science achievement versus the rest of the world, and only 52% even agree it is important for the U.S. to be a world leader in scientific achievements.  Ten percent didn’t think it was important at all. Young people, surprisingly, were most skeptical. 

I wonder what the doubters do think it is important for us to be the world leader in.

The problem may be that a third thought developments in science were changing society too quickly (43% among Republicans).  They want their new iPhones, they like fast internet speeds, they demand the latest treatments when they get sick, but somehow they don’t connect those to science.

I think about this when I read about the Texas board of education fighting about how science is taught in Texas schools. This year climate change and evolution were, again, hot topics.  Evelyn Brooks, a Republican board member, said: “The origins of the universe is my issue — big bang, climate change — again, what evidence is being used to support the theories, and if this is a theory that is going to be taught as a fact, that’s my issue. What about creation?”   

Ms. Brooks also declared: “There is no evidence that an entirely different species can come from another species,” which suggests she’s not keeping up with the fossil record or DNA analysis.

Never mind that evolution continues to be validated by finding after finding; some 40% of Americans believe in “creationism.” Never mind that the world has just passed the landmark 2 degrees Celsius above pre-industrial age global temperatures or that 97% of climate scientists agree humans are causing global warming and climate change.  Never mind all that because, you know, an outspoken minority don’t believe in science or in scientists.  And they’re determined to not help our children prepare for the world they’re inheriting.  

A recent study looked specifically at how climate change is – or isn’t – being taught in U.S. K-12 schools, and found that, indeed:

While planetary health education varies widely across the USA with respect to the presence and depth of terms, most science standards neglected to convey these concepts with a sense of urgency. Furthermore, state/territory dominant political party and primary gross domestic product (GDP) contributor were each predictive of the quality of planetary health education. 

We’re worried that artificial intelligence may kill us off, but plain old human intelligence (or lack thereof) may do that first.

All that, of course, assumes that we’re teaching our kids generally, but the evidence is pretty grim on that point – again, especially since the pandemic.  The pandemic led to drastic declines in math and reading scores (only 26% of 8^th graders are proficient in math, only 31% are proficient in reading). The National Science Board warns: “U.S. student performance on standardized tests in science and math has not improved in over a decade, placing the U.S. in the middle of a long list of global competitors,” and urges: “the U.S. needs “all hands on deck” to modernize K-12 STEM education and to hold itself accountable with reliable, up-to-date data.”

Some of that poor performance is because absenteeism has soared since the pandemic started.  According to Attendance Works, in the 2021-22 school year chronic absence affected nearly 30% of students.  Yes, it disproportionately impacted minority students and high poverty schools, but all schools and all demographics were impacted. Parents wanted schools to reopen in the early days of the pandemic, but evidently they weren’t as insistent that students actually attended.

------------

Science is a self-correcting endeavor, which means it isn’t always right at first. Scientists are human, which means they sometimes act out of impure motives. The pace of change enabled by science is, indeed, getting faster; just look at use of A.I. in the past year. But the “solution” to all that isn’t to turn our backs on science or to distrust scientists; it is to improve science literacy among all of us so that we are better equipped to adapt to what science offers us.

Hug a scientist – or better yet, help your children become one.

Pin Me, Please

You had to know I’d write about the new Humane AI Pin, right?

The Humane AI pin. Credit: Humane

After all, I’d been pleading for the next big thing to take the place of the smartphone, as recently as last month and as long ago as six years, so when a start-up like Humane suggests it is going to do just that, it has my attention.  Even more intriguing, it is billed as an AI device, redefining “how we interact with AI.”  It’s like catnip for me.

For anyone who has missed the hype – and there has been a lot of hype, for several months now – Humane is a Silicon Valley start-up founded by two former Apple employees, Imran Chaudhri and Bethany Bongiorno (who are married).  They left Apple in 2016, had the idea for the AI Pin by 2018, and are ready to launch the actual device early next year.  It is intended to be worn as a pin on the lapel, starts at $699, and requires a monthly $24 subscription (which includes wireless connectivity).  Orders start November 16.

Partners include OpenAI, Microsoft, T-Mobile, Tidal, and Qualcomm.

Mr. Chaudhri told The New York Times that artificial intelligence  “can create an experience that allows the computer to essentially take a back seat.” He also told TechCrunch that the AI Pin represented “a new way of thinking, a new sense of opportunity,” and that it would “productize AI” (hmm, what are all those other people in AI doing?).  

Humane’s press release elaborates:

Ai Pin redefines how we interact with AI. Speak to it naturally, use the intuitive touchpad, hold up objects, use gestures, or interact via the pioneering Laser Ink Display projected onto your palm. The unique, screenless user interface is designed to blend into the background, while bringing the power of AI to you in multi-modal and seamless ways.

Basically, you wear a pin that is connected with an AI, which – upon request – will listen and respond to your requests. It can respond verbally, or it can project a laser display into the palm of your hand, which you can control with a variety of gestures that I am probably too old to learn but which younger people will no doubt pick up quickly.  It can take photos or videos, which the laser display apparently does not, at this point, do a great job projecting. 

Here's Humane’s introductory video:

Some cool features worth noting:

• It can summarize your messages/emails;
• It can make phone calls or send messages;
• It can search the web for you to answer questions/find information;
• It can act as a translator;
• It has trust features that include not always listening and a “Trust Light” that indicates when it is.

It does not rely on apps; rather, it uses “AI Experiences” – on device and in the cloud -- to accomplish whatever goals smartphone apps try to accomplish.  The press release brags: “Instead, it quickly understands what you need, connecting you to the right AI experience or service instantly.”  

Ken Kocienda, Humane’s head of product engineering, contrasted the AI Pin with smartphone’s addiction bias, telling Erin Griffin of The New Times: “It’s more of a pull than pushing content at you in the way iPhones do.”

Health and nutrition is said to be an early focus, although currently it is mostly calorie counting.

The laser display. Credit: Humane

Ms. Griffin summarizes the AI Pin thusly: “It was, like any new technology, equal parts magic and awkward.”  Inverse’s Ian Carlos Campbell was also impressed: “Added together, the Ai Pin is exciting in the way all big swings are, the difference being it seems like Humane could back up its claims.”  

Mark Wilson of Fast Company, on the other hand, was more reserved, noting: “In practice, the AI Pin reminded me of an Echo Dot on your chest,” and wondering: “Where was all the magical stuff?...The stuff where, because the AI Pin is so overtly planted on our person, the rest of its demands could disappear?”    

Mr. Chaudhri defended using a pin instead of another version of smartglasses, telling Mr. Wilson:

Contextual compute has always been assumed as something you have to wear on your face. There’s just a lot of issues with that...If you look at the power of context, and that’s the impediment to achieving contextual compute, there has to be another way. So we started looking at what is the piece that allows us to be far more personal? We came up with the fact that all of us wear clothing, so how can we adorn a device that gives us context on our clothing?

Or, as Mr. Chaudhri said earlier this year: “The future is not on your face.”

Color Mr. Wilson unconvinced:

Humane’s issue in a nutshell isn’t that a wearable assistant is inherently a flawed idea, it’s that Chaudhri’s product doesn’t yet solve the problem he has diagnosed and set out to mitigate: that removing a screen will solve our dependence on technology…it appears Humane hasn’t unlocked the potential of AI of today, let alone tomorrow, nor has it fundamentally solved any significant problems we have with technology.

To be honest, it isn’t everything I’d hoped it’d be either. The AI is impressive but, at this point, still limited. The laser display is cool but not really ready for prime time. The pin is sleek, as would be expected from Apple alums, but I don’t want to even be aware of a device; I want it embedded in my clothes, maybe worn as a “smart tattoo.”  

But these are, really, quibbles. The AI will get exponentially more useful. The device will get much smaller. The display will get much better. As others have pointed out, the iPod was a revolution but was limited, and led to the iPhone, which itself was initially fairly limited.  Similarly, the AI Pin should get much, much powerful, and have even more awesome successors.

In the press release, Ms. Bongiorno and Mr. Chaudhri say:

AI Pin is the embodiment of our vision to integrate AI into the fabric of daily life, enhancing our capabilities without overshadowing our humanity. We are proud to finally unveil what we and the team at Humane have been working on for the past four years. For us, Ai Pin is just the beginning.

The introductory video closes with Mr. Chaudhri promising: “It is our aim at Humane to build for the world not as it is today, but as it could be tomorrow.”  We should all be designing for that.

About That Next Generation of Clinicians...

I saw a report last week – Clinician of the Future 2023 Education Edition, from Elsevier Health – that had some startling findings, and which didn’t seem to garner the kind of coverage I might have expected.  Aside from Elsevier’s press release and an article in The Hill, I didn’t see anything about it.  It’s worth a deeper look.

It's an uncertain future for clinicians. Credit: Bing

The key finding is that, although 89% say they are devoted to improving patients’ lives, the majority are planning careers outside patient care.  Most intend to say in healthcare, mind you; they just don’t see themselves staying in direct patient care.

We should be asking ourselves what that tells us.

The report was based on a survey of over 2,000 medical and nursing students, from 91 countries, as well as two roundtable sessions with opinion leaders and faculty in the United States and United Kingdom.  Since I’m in the U.S. and think most about U.S. healthcare, I’ll focus mostly on those respondents, except when they’re not split out or where the U.S. responses are notably different.

Overall, 16% of respondents said they are considering quitting their medical/nursing studies (12% medical, 21% nursing), but the results are much worse in the U.S, especially for medical students – 25% (nursing students are still 21%).  That figure is higher than anywhere else. Globally, a third of those who are considering leaving are planning to leave healthcare overall; it’s closer to 50% in the U.S.

Credit Elsevier, Clinician of the Future report

Tate Erlinger, vice president of clinical analytics at Elsevier, noted: “There were several things [that] sort of floated to the top at least that caught my attention. One was sort of the cost, and that’s not limited to the U.S., but the U.S. students are more likely to be worried about the cost of their studies.”  Overall, 68% were worried about the cost of their education, but the figure is 76% among U.S. medical students (and for UK medical students).  

Having debt from their education is a factor, as almost two-thirds of nursing students and just over half of medical students are worried about their future income as clinicians, with U.S. medical students the least worried (47%).

It’s worth noting that 60% are already worried about their mental health, and the future is daunting: 62% see a shortage of doctors within ten years and 64% see a shortage of nurses. Globally, 69% of students (65% medical, 72% nursing) are worried about clinician shortages and the impact it will have on them as clinicians.

Where it gets really interesting is when asked: “I see my current studies as a stepping-stone towards a broader career in healthcare that will not involve directly treating patients.” Fifty-eight percent (58%) agreed (54% medical, 62% nursing). Every region was over 50%. In the U.S., the answer was even higher – 61% overall (63% medical, 60% nursing).

Dr. Sanjay Desai, one of the U.S. roundtable panelists, said: “I know this might evolve as they go through their education, but 6 out of 10 in school, when we hope that they’re most excited about that career, are looking at it with skepticism. That is surprising to me.” 

Me too.

The ratings on the education they are getting are good news/bad news.  Seventy-eight percent (78%) agreed that their school is “adequately preparing me to communicate and engage with a diverse patient population,” and 74% that the curriculum has been adapted to the skills that today’s clinicians need, but, honestly, wouldn’t you hope those percentages would be higher? 

Perhaps this is explained in part by only 51% reporting they have used A.I. in their training and only 43% agreeing their instructors welcome it.  The latter percentage is 49% in the U.S.  Overall, 62% are excited about the use of AI in their education, although only 55% in the U.S. (57% medical, 53% nursing).

Similarly, 62% think the potential for AI to help clinicians excites them, but only 55% in the U.S. (58% medical, 52% nursing).  Seventy percent (70%) think AI will aid in diagnosis, treatment, and patient outcomes, but, again, the U.S. lags: 64%, same for medical and nursing. Still, only 56% (globally and in the U.S.) agree that within 10 years clinical decisions will be made with the assistance of AI tool.

Dr. Desai was emphatic about use of AI: “It’s here and it’s going to stay. There are some who have said that we should slow down until the frameworks and the guardrails for ethics and for appropriate use, etc., are in place, and I think that’s wise. But I think we need to accelerate that, because as technology outpaces our organization of the space, there are risks.” Another U.S. panelist, Dr. Lois Margaret Nora, was more circumspect: “AI can turn out great, and it can turn out really terrible, and understanding the difference, I think, is an issue that is going to be very important in education.”

More broadly, 71% believe the widespread use of digital health technologies will enable the positive transformation of healthcare, although only 66% in the U.S., but 60% fear that will be a “challenging burden on clinicians’’ responsibilities.” For once, U.S. students were less pessimistic: only 52% have the same fear (51% medical, 54% nursing). 

-------------

It’s disturbing but not surprising that a quarter of U.S. medical students, and a fifth of nursing students, are considering leaving school.  The lengthy time it takes and the corresponding debts are daunting.  Of more concern is that so many – over 60% for both medical and nursing students – are already planning for a career that doesn’t involve patient care. Are those schools the right place for such students?  Have careers involving direct patient care become that bad? 

It's also clear that the world is changing more rapidly than medical/nurse schools or their students.  They’re not ready for an AI world, they’re not even fully prepared for a digital health world. These students are going to be the vanguard in deploying the new tools that are coming available, and they’re neither adequately trained nor quite enthusiastic about them.     

Jan Herzhoff, President of Elsevier Health, summarized the report’s implications: “It’s clear that healthcare across the globe is facing unprecedented pressures, and that the next generation of medical and nursing students are anxious about their future. Whether through the use of technology or engaging learning resources, we must support students with new and innovative approaches to enable them to achieve their potential. However, the issues raised in this report can’t be tackled in isolation; it is essential that the whole healthcare community comes together to ensure a sustainable pipeline of healthcare professionals.”

Let’s get on that, then.