This post has many spoilers for You Can See Everything.
The internet is chock full of hot takes on the most talked-about movie in a long time, You Can See Everything, which is a “documentary” about Elizabeth Holmes shot in her home a month before she went to prison for defrauding investors as the founder of Theranos and then told more through reenactments in the second half of the movie. I have written columns about Holmes and am a big fan of the other protagonist/co-director Nathan Fielder. So, I was captivated by the movie, laughed very hard, and it has stayed in my head, like it seems to do with other people.
Although I was captivated by the skill with which Fielder and his co-director Lance Oppenheim rendered this movie, like many who have read John Carreyrou’s masterful book Bad Blood and studied the case, I didn’t believe a word of it. I think the two best columns from that side so far are this take by Carreyrou and this one by Tyler Shultz who was one of the whistleblowers inside the company. If you’re familiar with the way in which Holmes misled everyone in the first round of this story, it’s hard to take anything she says in the movie seriously. Nevertheless, because of Fielder and Oppenheim’s skill, many people see the movie as perhaps suggesting that Holmes someone who “thinks differently” and maybe was telling what to her was the truth the whole time.
Nathan for us
If you’re not familiar with Fielder’s work prior to this, you can watch a few quick episodes of Nathan for You where he peddles unorthodox marketing ideas to small business owners. This includes “convincing” a yogurt shop owner to market “poo-flavored yogurt” and “convincing” gas buyers to do an all-day mountain climb to get $10. I put “convincing” in quotes, because we have no real knowledge of whether these people bought this. For all we know, Nathan said before the camera went on, “I’m going to suggest you sell poo-flavored yogurt and I want you to go along with it.” Given the stakes of the show, I don’t care. I find it funny and Fielder is hilarious.
The Rehearsal was a rehearsal for You Can See Everything
His next, much bigger, show is The Rehearsal on HBO Max. In this, he has people do elaborate pre-enactments of challenging human interactions upcoming in their lives to make them better prepared for the real challenges. This goes as far as Fielder learning to pilot a 737 for a season about communication problems in commercial cockpits. On one episode, he becomes interested in whether one of his participants is autistic, and goes to an autism clinic where he is shown the reading the mind in the eyes test for which he gives a lot of wrong answers. The bit is that Fielder is himself awkward with a monotone voice, flat expressions, and clear inability to pick up on social cues, so we’ve been thinking he was autistic the entire show. It stops short of Nathan getting the final result of his test or identifying himself as autistic, and the truth is, we don’t know how much of his on-camera persona is the real him or an act. But one thing is for sure, given the much larger stage that he is now on with Elizabeth Holmes, The Rehearsal was a rehearsal for You Can See Everything. It installed the idea that maybe Fielder is autistic and allowed him to perfect his reenactment shtick, which goes to 11 in the Holmes movie.
‘Because that’s what we invented’
In an effort to convince Fielder that she has always told the truth, Fielder and her partner (Billy Evans), go out to the garage to get the pieces of the (supposed) Theranos device to show that it works. They were living in a rental prior to her incarceration, so I had to wonder why they would have thought to bring this along to their temporary housing. And, as Tyler Shultz pointed out, this was a later iteration of the device, not the one for which Holmes went to prison. Nonetheless, they put the pieces on the dining room table, and Holmes starts explaining why she was being truthful in saying that it works.
As Fielder presses her as to how the device could run multiple tests on a drop of blood, she keeps coming back to the statement, “because that’s what we invented.” She said what they invented is a device that could download instructions for a protocol from the internet, carry out that analysis on the device, and then download a different set of instructions, and then carry out a different analysis. And then so on. So, she’s suggesting that what is novel is the ability to reprogram the device for different tests from the internet, thereby allowing it to run multiple tests.
Fielder then takes her down a rabbit hole of whether the fact that the device potentially could run multiple tests versus whether it really did. The point of this seemed to be to establish that Holmes has a very narrow and literal view of the world that provided her an avenue to be telling the truth even though the device never actually did anything that she claimed. More on this line of thinking below.
But you don’t really need to go that far. The better question is whether “because that’s what we invented” is even correct to begin with. I went to the patent literature to find what invention Holmes was referring to. My best guess is that she’s referring to is US Patent No. 9,121,851B2. Before analyzing this, it’s important to explain the difference between independent and dependent claims in a patent. An independent claim stands on its own, although it has to be interpreted in light of the text in the patent. A dependent claim is only valid when applied to the invention in the independent claim.
The independent claim in the relevant Holmes patent is:
1. A system for detection of a first analyte and a second analyte in a biological sample, comprising:
i) cartridge comprising a housing carrying a plurality of movable assay units configured to run chemical reactions on portions of said biological sample, wherein said chemical reactions are configured to yield detectable signals indicative of the presence or absence of said first analyte and said second analyte in the biological sample, wherein said housing is configured to carry a plurality of reagent units;
ii) a plurality of movable reagent units separate from said housing, said reagent units being filled with reagents for running said chemical reactions, wherein individual reagent units are calibrated with reference to corresponding assay units;
iii) a pipette assembly configured to transport aliquots of fluid and to transport assay units, said pipette assembly comprising pipette heads configured to engage said assay units; and
iv) a detection assembly for detecting said signals indicative of the presence or absence of said first and second analytes in the biological sample.
This is a general description of the Theranos device. Note, there’s nothing in here about programming the device from the cloud. Only if you look at the dependent claims do you see what Holmes tells Fielder about:
22. The system of claim 1, further comprising a communication assembly, wherein said communication assembly is configured to transmit information, to receive information, or both.
23. The system of claim 22, wherein operation of said system comprises operation according to a protocol, wherein said protocol is configured to incorporate information received by said communication assembly.
24. The system of claim 23, wherein said protocol is configured to be adjustable without requiring modification of the system.
So, Theranos only patented the idea of reprogramming from the cloud for their device. It didn’t take me long to find a prior patent, US Patent No. 6,963,907BI, with a priority date 13 years earlier, that has this independent claim.
1. A method of operating an Internet device for remote medical testing comprising:
downloading via the Internet a medical testing program from a server, said medical testing program being utilized to provide non-invasive cardiovascular function related test measurement data;
coupling at least one non-invasive sensor to said Internet device, said at least one sensor being non-invasively coupled to and disposed on a patient to obtain impedance test measurement data;
executing said test program to obtain said test measurement data from said at least one sensor;
automatically uploading said test measurement data to said server via the Internet;
automatically analyzing said test measurement data at said server to provide cardiac function test data;
storing said test measurement data and said cardiac function test data for said patient in a database accessible by said server;
operating on said test measurement data to produce substantially real time waveforms of said cardiac function test data;
maintaining a history of test measurement data and cardiac function test data for said patient;
utilizing a trending algorithm on said history to develop a medical condition trend for said patient;
receiving processed cardiac function test data from said server as a download from said server via the Internet; and
displaying said processed cardiac function test data.
There are probably earlier examples, but this patent establishes that the idea of downloading instructions from the Internet to operate a medical testing device was already patented years before Theranos. Holmes may have patented a particular implementation, but she can hardly claim to have invented the underlying concept. Fielder wasn’t searching the patent literature, so I can understand why he focused on the difference between can and did rather than boring people with arcane patent claims. Still, Holmes’ veracity is perhaps more directly challenged by asking what she really invented.
I don’t know is on third
Since Fielder was more interested in determining whether Holmes’ mind was just so literal that she thought she was telling the truth, he showed her the famous “Who’s on First?” sketch from Abbott and Costello. The hypothesis, I guess, was that if she was so literal in her thinking, she wouldn’t get the joke. She laughed during it but then said she just thought the way they were acting was funny. When Fielder explained that the first baseman’s name was Who, it still didn’t register. John Carreyrou has commented that one of the things that makes it unbelievable is that she didn’t say, “Oh, I get it,” when Fielder explained the joke. For all we know, before they watched it, Fielder said, “I’m going to show you the Who’s on First sketch now, and I want you to act like you don’t get it.”
Billy Evans then uses this episode to launch into an analysis of how Holmes just “thinks differently.” That the way her mind works, she could be saying the device worked because of some very narrow way of analyzing “what she invented.” We never move from “think differently” to autistic or neurodivergent, but that’s clearly the implication.
Theory of (Liz’s) mind
The reason autistic people sometimes have trouble with a joke like Who’s on First has to do with what Simon Baron-Cohen long ago termed “theory of mind,” which is the ability to intuit what someone else is thinking. The classic experiment in this concept is the “Sally-Anne” experiment where children are shown a story board about someone named Sally who puts a marble in a box. She leaves the room and then another child called “Anne” comes and moves the marble to a basket. Neurotypical children will say — when asked where Sally will look for the marble when she comes back — that she would look in the box where she thought it was. But autistic children are much more likely to say that Sally will somehow look in the basket because the idea that she was tricked doesn’t register.
This lack of theory of mind is often couched as a lack of cognitive empathy, which differs from affective empathy. Cognitive empathy is the ability to guess what someone else is feeling, affective empathy is the ability to identify with the feeling. Autistic people often have low cognitive empathy and high affective empathy. Liars and manipulators tend to be the other way around - you need to be able to deceive another person and not care about hurting them. If you read Bad Blood and Tyler Shultz’ STAT piece, it is nearly impossible to see how Holmes could have done all the things she has done — including raising nearly $1B — without excellent cognitive empathy/theory of mind. Whether she did or did not understand that What was on second base is something we’ll never know.
Fielder has made a career out of confusing us about whether the people on his shows are really behaving the way they appear to be, or whether they’re in on the joke. No yogurt proprietor would believe that poo yogurt would outsell chocolate-vanilla swirl. Holmes made a career out of convincing people that what they were seeing was something other than what it was. In You Can See Everything, these two titans of deception get to clash. When Fielder does it, we laugh — and boy did I laugh at his latest and greatest achievement. But when Holmes did it the first time, investors lost hundreds of millions of dollars and patients nearly got the wrong health information and could have died. And the most impressive trick in the movie is that Fielder almost gets us to forget the difference.