The Doctor is in: Clinician led Innovation and Investing in Medtech | LSI USA '23

Transcription

Tyler Burch  0:09  

I'd like to introduce the panel The Doctor Is In: Clinician Led Innovation and Investing in med tech. Our moderator here is Maggie, Judge, Chief of Staff at Inner Cosmos had the pleasure of talking to Maggie some last night and she's going to do a brilliant job here. A little bit about Maggie, she is a strategic and forward thinking registered nurse with a wide variety within a wide range of of key fields. Maggie has taken her experience in the nursing field to be a creative leader. With a deep understanding of process procedure, and a proven history of turning vision into reality. Maggie excels at strategic strategy and implementation, project management, creating processes, analyzing and solving complex problems, as well as leading a team in a fast paced dynamic atmosphere. Maggie the floor is yours.

Maggie Judge  0:58  

Well, thank you, everybody. I'm really excited that I have a microphone. Those of you that know me know I do not need one. So Thanks for Thanks for the introduction. I would love to let the team explain their experience and what they bring. So I would love to just open the floor and we can start here and let you tell us a little bit about you.

Dr. Qasim Butt  1:18  

Okay, well, I'm Dr. Qasim Butt, but I'm a recovering nephrologist. I'm kind of in relapse right now. I'm going I'm going in between clinical and non clinical. I'm doing working at UT Health San Antonio and I'm doing some medical consulting as well. I'm with two LSI alums actually, Alio Medical,nephrology medical director, and Ikona Health, which is a CKD education platform. I'm advisor to them. And that's who I am, yeah, and investor as well too.

Dr. Monica Jain  1:48  

Hi, there. I'm Dr. Monica Jane. I am a general and endocrine surgeon and the surgical innovation officer at Cedars Sinai, just north of here, as well as a partner at WaveMaker 360 health which is an early stage, Digital Health Medical Device fund. I do a lot of work also in human factors, understanding processes and usability and have a background in engineering as well. So personally, I like to sit at the intersection of all of these areas.

Rishad Usmani  2:19  

Hi, I'm Rishad, a family physician, founder of one failed startup angel investor and now I run HealthTech Investors, which is an angel syndicate of 500 physicians. We invest in early stage healthcare companies have a focus on education.

Matthew Savary  2:33  

I'm Matthew Savary, I manage the med tech track of the UCLA Innovation Fund of proof of concept fund at UCLA. By way of training, I was a general surgeon at Beth Israel in Boston, before becoming the Medical Director for Safety at Medtronic.

Ruben Osnabrugge  2:50  

Ruben Osnabrugge, I'm a trained cardiothoracic surgery in a rosboroughs embsay. In the Netherlands in Rotterdam work at the equity Life Sciences now, which is a leading European Life Sciences FISI. We invest in medtech drug development, but also in diagnostics and digital health. Yeah, in between, I spent two years at Philips. So yeah, but very happy where I've landed now.

Maggie Judge  3:14  

Wonderful. All right, let's get into it. So I would love to know, how do you think your clinical background and worked on bedside gives you an edge over non clinical entrepreneurs and investors?

Ruben Osnabrugge  3:26  

I can go first. I think there is a balance between subject matter experts having biases which can be harmful for de novo startups and startups that are very disruptive. And startups that are going to market within the two years, I think two years is the threshold of when we cannot predict the future beyond two years. So if you're going to market within two years, and if you're falling 510 K pathway, then clinicians can add a lot of value as usually you are your marker of success as well, physicians clinicians use your products. But if you're doing something very disruptive that will not take the market in 15 years, then sometimes we can cause more harm than good because we are stuck in our biases of will I use this right now. Not will the future 15 year old 15 year me I had me will use.

Dr. Monica Jain  4:21  

So I think that clinicians definitely add a lot of expertise. I think they really truly understand the market and which and a device is going to land and I completely agree with you that that is definitely a short term. But they understand the processes the workflow, they understand what it would take to get someone to change their practice. And so I think that clinicians really help in that area. And helping the implementation and adoption, which is especially where a lot of startups fail, is thinking about that aspect. So I think that clinicians are especially helpful in that area.

Maggie Judge  4:59  

Yeah, absolutely. When do you think is a great time for a non clinical based company to start onboarding clinical based team.

Matthew Savary  5:09  

I'll jump in here. And I'll just say immediately. So one of the hazards for believing that you've identified an opportunity for innovation in clinical medicine and medtech, is that there are a lot of, there are a lot of stones in the stream that are not self evident unless you've already operated in that space before. And so when you're trying to evaluate the value proposition of any kind of technical innovation, it's easy to bias towards the technical side of it, rather than the clinical side of it. And so, I know a lot of clinicians who are really interested in getting involved in this space, either from just one off conversations to weekly conversations to monthly to quarterly. So it's not even particularly difficult to find somebody who'd be interested in having that kind of conversation with you. And validating that, that value proposition as early as possible, is really important to me.

Ruben Osnabrugge  6:05  

Yeah, so maybe something to add to a lot of our portfolio companies actually are part of a program like Bioinnovate in Ireland, or Biodesign. Here in California, I think that also really goes into the unmet clinical needs, and then think of solutions. So typically, so I haven't been in the program, but what I hear from the entrepreneurs that we invest in is that they identify unmet clinical needs, make, make a whole list of them, and then identify the the ones that are most likely to make the DNS considering all other factors, but it starts with the unmet clinical needs.

Dr. Qasim Butt  6:43  

Yeah. I mean, even from a physician, like, it depends on to me, I know, you're talking about the biases with, you know, long term projects, or whatever, or long term horizons, but even like, you know, with physicians, like myself that have been there for like, 10 years, you know, we've, we've seen it for longer, so we can see how that product may fit in our clinical workflow she mentioned, but also, what's the path to, you know, revenue? Right? I think so many people have a great product, great idea, but there's no path to revenue, and how who's going to be the payer? And so that's another thing I think a clinician can add? Is it the is it the payer, the user? Is it the insurance company? Is that the physician? Is it the patient who is gonna actually pay for the product itself? So

Matthew Savary  7:25  

just before we move on, I just want to offer a counterpoint to the cop to the shots comment about the instinctive conservatism of some clinicians, I think that one of the benefits of having a clinician on your team who is who does have an innovative mindset is that it's easier for them to look at things from first principles, because they appreciate precisely what you're trying to get accomplished within a clinical setting, outside of what they're already already comfortable with providing a very good example of that I'm not going to call you out, I'm not gonna point to you but somebody in the room is one of our clinician innovators from UCLA, who's identified an opportunity for revolutionising eyes surgery. And if you had found one clinician who looked at it from a more parochial point of view, obviously, that kind of person would say, we already do it this way, it's natural to stay in this way. This means but if the clinician already understands the physiology of what they're trying to accomplish with their surgery, or that the procedure, it's easier to convince them of the value proposition of something that doesn't have an obviously, self evident business model immediately.

Rishad Usmani  8:33  

I agree with that statement. If you find an entrepreneurial DNA physician, a physician with a strong bias to action, then that is gold. And you should hang on to that. And I think, what Matthew referring to as those particular physicians, I would say that is not the majority of physicians. But if you can identify those physicians, and they are invaluable, because they can add the clinical ROI, and also define your financial ROI. And to be somewhat blunt, a startup is product and sales. And I would say sales and product are both equally important.

Maggie Judge  9:11  

So do you think investors are more willing to write a check for a company that has clinicians leading the home or not?

Rishad Usmani  9:21  

As an investor myself, if you ask first time founders with the most important thing, because they'll say product, if he asked second time founders, they will say distribution. So if you're a clinician trying to raise, I want to see your commercialization plan. I want to see your distribution strategy, especially if you're a first time founder, which I find a lot of clinicians are.

Dr. Qasim Butt  9:43  

I mean, I just talked to one founder this morning, and he's here raising money as well. I'm not gonna say who he was what he wanted to do, but you know, he was in the kidney care space. And he actually said he brought some physician on board just to say as as investors just to say, because some VCs will be like, How come there's no nephrologist On your in your in your on your board or in your advisory? Or how come they haven't invest? How come they haven't bought in? So I think just having that buy in from a physician to legitimize what you're doing, it's kind of important to, absolutely,

Dr. Monica Jain  10:12  

yeah, from my standpoint, as an investor, it's a hard No, if there is no clinician expert in the space that you're working in, that is on your team, and more incorporated into your team, not necessarily full time, but at least regular contact, there's a big difference. But in development, when you have a clinician in that space, actually working with you in the development and commercialization process, rather than just having an advisory board and someone who you talk to every six months or something like that, that just says, Yeah, that sounds good, or no, that doesn't sound so great. And that development process and understanding how to develop in the right way, I think makes a huge difference. And so for me, it's always engaged the experts early, I want to see a clinician on your team. And if you don't have that, then I personally, regardless of how awesome your technology is, think that you're going to hit that hurdle when it comes to the distribution, commercialization adoption, and I'm not going to go for it.

Dr. Qasim Butt  11:13  

Can I ask you a question? We are in that like, do you think that clinician has to be in the specialty of what you're providing? Or can it be kind of related? Or?

Dr. Monica Jain  11:21  

Yeah, I think it depends on the product, right, because there's some products that have many specialties that they could apply to. And so it kind of depends on what you're looking for. Now, if you're doing an education, like a company that is doing education in kidney care, I think I should see a nephrologist, a dialysis nurse, like some clinician in that space, if you're doing a product that is a surgical tool, it could be any type of surgeon, it doesn't have to be that first target market that you're going after, like cardiothoracic surgeons, it could be really any kind of surgeon, but just someone who has been in an operating room and has operated, right, so someone who has that experience, and I think that that makes a big difference.

Maggie Judge  12:06  

No, I agree. Um, what are some issues that you've seen in transferring from bedside to the entrepreneurial space? Excuse me? And how did you overcome those? 

Ruben Osnabrugge  12:17  

Oh, sure, no worries. So I think, to the entrepreneurial space, I think that there's actually more similarities to the step that I'd free to do in between being in a big corporates, because they need to convince a lot of people I haven't practiced in the US. But in the Netherlands, in hospital, especially in surgery, if you make a decision, things happen in the middle of the night or during the day doesn't matter that things happen quickly. In general, in business, you need to convince people, you need to get people on board, you need to manage your stakeholders. That's something that I really experienced when I was at Philips. Now being closer to the entrepreneurs, I see that they make very well thought of decisions, but it happens quicker. So I think in some sense clinicians, they are actually quite shrewd, most of them are quite suited to the entrepreneurial spirit, I would say, in general, because you also have to figure things out on the go, how many is like see one do one teach one. Right? So that's also a little bit in an entrepreneurial space, I would say. But I'm happy to hear your thoughts. Yeah.

Matthew Savary  13:21  

What I'd like to add to that is one of the at least the way that I was trained was trained in general surgery, one of the most important things that we were always held accountable for was being the expert on whatever was happening at any given time. And one of the things that I learned and moving to the commercial space, is that it's kind of your responsibility to flip that and make sure that you when you absolutely should know your business and technology cold, it makes me feel very frustrated when hearing from people who feels like they read about in the back of a magazine. But it's a good idea to have people who absolutely know more about you in whatever their functional domain is, than at any given time, especially when you're running a company. So that's the big, temperamental difference that I noticed between those two spaces.

Dr. Qasim Butt  14:11  

The other thing I would say is, you know, as I've made this kind of halfway journey, like you have to get used to chaos and managing chaos. And so it's like, it's weird, especially a part of a startup, you're like, what's my responsibility? Exactly? Who do I report to? All that kind of stuff kind of comes up as well, too. And I think the other big thing is the opportunity cost of leaving medicine is what inhibits a lot of physicians from leaving it. But it's hard to match that salary in other places, and it takes time. So I think that's one of the big things. So that is a big one. Yeah,

Rishad Usmani  14:41  

I'll just add one thing. I think we are intuitive problem solvers and great at decision making. We know how to balance structure and intuition and decision making, and that is an invaluable thing to have in a startup journey.

Dr. Monica Jain  14:59  

I think that I completely agree with you. That's the number one thing for me is that doctors or clinicians in general are problem solvers. We work under limited resources, a lot of the time, especially now, with our staffing constraints and things like that we're always busy and kind of trying to figure out things on the fly. We're used to responding to codes, you know, all that sort of stuff that is the same in startups, just not patients, but you know, things related to your company. But we're, it's all the same skills, I think where we lack is that, especially as a surgeon, we're usually at the head and making all of the decisions. And as Matthew said, used to knowing everything about every piece of what we're working on, and knowing exactly what's going on with anesthesia with our instruments with the patient, whatever it is. And it's difficult sometimes to make a transition into a field where you don't know what's next. And you don't have control over every little piece. And so I think that's where there's a little bit of a struggle.

Maggie Judge  16:05  

I think that's kind of what brought us all into entrepreneurial ship is the the thrill seeking of the unknown. I love that part. But, you know, coming back to what you said about managing chaos, I think one thing that sort of an unseen task that we do is triaging. So when you walk into a room full of chaos, immediately, our brain has 10 things to do. And we know which order to do them. And most of the time, we're doing all of them at the exact same time. So that I see is something that we bring to the table, when you walk into a room, we can really help organize and bring things to life in a more streamlined fashion. Because it when when a patient's on the table, and it's life or death, it's it's a pretty big moment. So I'm we I know we have a lot of clinicians in this space now. And you know, they're beginning their the beginning of their journey. So what is a piece of advice that you have for them that you wish you would have had at the beginning of your journey?

Matthew Savary  17:08  

I can give advice that I actually did get, which is better. This doesn't come naturally to clinicians, and has come more and more naturally to me over time is networking is so important. And it feels at least for me, it felt in the beginning, it felt smarmy and artificial, and difficult. But the most up to date information about the most important things is inside people's heads doesn't exist in any database that doesn't exist in any textbook. So if you want to understand the next step that you need to take for reimbursement for regulatory for making, taking your product to market, your commercialization strategy for your HR strategy, it's because you know, somebody who knows somebody who knows something. So the advice that I got when I got started was to take five informational interviews, which felt very unnatural. And ask those for five people to talk to another set of coffees and ask all of those take me to another set of coffees. And one it makes you feel want to kind of like D stigmatizes like the networking atmosphere. Because now that I do what I do, networking is just kind of like my job. And then to is, it expands the opportunities that you're even aware of. So one of the shortcomings of the clinical path is that clinical medicine is a railroad track. So you get on you do your residency, you do your fellowship, you do your you get your first job, and et cetera, et cetera, et cetera. But the world of business is a jungle gym, and you don't know what's out there unless people can tell you what where the other rungs are. So that's my bit of advice.

Ruben Osnabrugge  18:46  

Yeah, what I can add to that is actually to find a great mentor, because like, I need to have all those conversations, but also just to have one or maybe two people that you can really like long term rely on and bounce off ideas with, I find it very helpful, especially your you go into a whole new world.

Dr. Qasim Butt  19:03  

i I'm sorry, I was I totally agree with that. Like that's one of the things I did when I started looking into med tech and stuff is to talk to physicians that actually were in this space. Because when, like any of us talk to regular doctors that are just in the day to day we sound crazy. And so you need that guidance that hey, this is possible. This is what you have to do. And I think that's you know, I think that's kind of crucial is to actually reach out to physicians that have already made it that have been medical consulting or venture capital or whatever they've done, and see how they got there and see how you can do the same so

Rishad Usmani  19:36  

Oh, sure advice I got and ignore it and I wish it didn't. Which is when you're when you're making your founding team. Hire for commitment. Don't hire the Rockstar. Don't hire someone who looks really good on paper. Hire someone who believes in you your mission and who you get along with, who have you struggled with in the past and are still friends with them. And the second piece of advice I would give as well. When you are looking at what problem to solve, focus on the problem. Now the solution, once we start building things, we get distracted by how good or how flashy or thing, look on paper. But really stay focused on the solution or the problem you're solving.

Dr. Monica Jain  20:22  

That's, that's great advice, I really want to double down on that, actually, because a lot of times the biggest pain points in our lives as clinicians are not the biggest market, or the biggest problem out there to solve that would make a good business. And so just because it's really awful for you doesn't mean that it's really awful in that same way for everyone else. And so a lot of times, especially for clinician born companies, they're solving a big problem for themselves, and then kind of get stuck in that process of expanding this to everybody else. And so, really understanding the core of the problem understanding and clinical need, understanding the market that's out there, which I think a lot of clinicians struggle with. Because you know, every problem is a big problem. And every problem affects our patients lives in some way. And so But understanding how to find the biggest problem that you can tackle and something that is also within your wheelhouse to tackle really makes a big difference. And so I think that clinical need portion is especially important. And also I will highly, highly second the networking aspect of this because that networking portion makes such a big difference. Because like as, as clinicians, we're often just like lone warriors out there, like you're in clinic by yourself, you're in the OR, and you have a team, but really, it's you, you're leading the team. And in the situation, it's very different. And you have all of those experts around you. And the only way you find those experts is by networking at events like this, and meeting those people who are going to steer you in the right direction.

Maggie Judge  21:57  

I think that's a beautiful point you, you see really great products and companies get lost. Because they feel that because they don't have that entrepreneurial business background, that they bring on certain advisors, and they start networking and everybody has an idea for your company and how they should push it and where they want it to go. So what's some advice for those companies where they feel like they're, they're at that that crossroads? And then they have a lot of people coming at them, but they're not quite sure? How do you know what advice to listen to? And where to go? And do you have some some thoughts on that? I know you do. 

Ruben Osnabrugge  22:36  

it's actually very, so how do you know who to listen to? Who knows? Right? So maybe you have the benefit of listening well to patients? Maybe some not so much as a CT surgeon, but in general, as a physician, you need to listen well. And so a little bit of your gut feeling to be honest, like, like, which which mentor would you trust? Which one would you go to and try to pick someone who's actually completely out of your fields? Like, I really want to have the most successful businessman who I thought initially was a little bit slick. But that person is actually really good. So I need to learn from him and or her. So yeah, that's, that's yeah, I don't know, there's no formula, I would say,

Matthew Savary  23:19  

Do you mind if I go here, 

Maggie Judge  23:20  

get in there.

Matthew Savary  23:21  

So I was lightly triggered by this one, because we manage the the startup portfolio of the university. And it makes me feel very frustrated when I encounter this problem. The issue is you have to have a point of view. And the point of view, you can hold on to it with your fingertips hold on to it firmly. But you should be able to have it be pulled out. But you have to have a point of view. And having a point of view makes it easier for you to ask questions and ask directed questions. And those refine that point of view, but they don't inform it. It makes me feel frustrated when I'm meeting with a team serially over time. And every time that I meet with them, they have an entirely new strategy. And I'm like I know exactly who you just talked to 60 seconds ago. And that just makes me feel like like you don't have a vision for your company, you don't have a vision for what this technology is supposed to be. So if you have a vision, if you have a point of view on what the what you're trying to accomplish, then getting that informed by multiple points of view, just makes it better. But if you don't have a point of view in the first place, you just get buffeted around like a piece of litter in the wind. So but didn't sound too negative.

Dr. Monica Jain  24:27  

That also doesn't mean that you only find the people who agree with you, right? Like I think that the point is very valid, but you also have to find the people who contradict you. And then instead of like just blindly accepting whoever comes at you, I think you have to kind of then go and explore that a little bit more. So it's, it's a difficult position to be in, especially if you don't have the expertise in those areas. And so getting as many points as perspectives as possible, is what I think helps because if multiple people are telling you the same thing, then that's probably what is true, rather than this lone person here and this lone person here, and then again, it comes down to networking and talking to a ton of different people and getting perspectives.

Matthew Savary  25:11  

So I want to double down on that, because the or explore that a little bit more. Because I think that what you pointed out is that the object here is not just having a point of view, it's having a hypothesis and then going out there and testing that hypothesis or validating that hypothesis. So the objective isn't necessarily to confirm it, even though if you did confirm it, that'd be great. You have more information now. But to walk out there with a hypothesis about what the value proposition is, what the path to market is, what the regulatory strategy is, and then having that validated is great.

Maggie Judge  25:45  

Yeah, it's really interesting with with pivoting, and having people who can poke holes, and finding that, that that balance. I know, we have lots of people attending and I just wanted to take a second to see if there's anybody in the audience who might have a question for anyone on our panel. Any advice you you'd like to seek real quick before we move forward? No, can't see. Okay, you're quiet out there. All right. So we did such a great job of answering all of their questions. I think it's fantastic. You know, when you when you watch, especially like on the nursing side, and sales, and this has been a really big topic, and something that I really love to talk about, because you know, you it's really hard to navigate the hospital system. I mean, even as somebody who works in the hospital system, it's changing every hour. And so how do you feel clinicians transfer over into a sales team, not even as an entrepreneurial are an investor, but building your sales team of clinicians who truly know that space?

Dr. Monica Jain  26:51  

Well, I think clinician KOLs are the ultimate when it comes to selling into health systems. And so having that Kol makes a big difference. And if it's the founder, who is the Kol, I think that helps a lot. Because you truly understand your value proposition, you understand what your business direction is, like, you have that understanding as a clinician founder, and then going out to sell. However, the part that I will bring, the other side of that is that they have a lot of bias and thinking obviously, like their solution is the best. And so then sometimes that can be off putting to having someone else out there. And so I think you have to kind of have a team of KOLs that's developed in that way. And a clinician founder is the best person to understand who can build out that team. So that you really have the balance of people who believe in what you're doing, but then also aren't as biased as that clinician founder is.

Rishad Usmani  27:51  

Yeah, I think that's really well said clinicians have a bias towards, if it adds clinical value it will sell. But there's a lot of tension between what health systems want, what insurance wants, and what clinicians want. And sometimes what patients want to understand all those four players is important. And to understand who is driving and generating your revenue is very important and focus on that. Sales is about listening and solving problems. And I think most clinicians that I come across, and I'm generalizing here, would benefit from even an hour of sales training. So I think that's something that we should, as investors, maybe we should take that on, and do that for our clinician founders.

Ruben Osnabrugge  28:36  

Maybe just to add something from an investor perspective, who we do see, of course, in certain areas, we see specific KOL's being tied to all of the different companies. So it doesn't mean that when you really trying to find out, if that company that technology is going to work, you don't need to necessarily rely on these top KOLs, because they will be involved in any of them, and they want to feel to be developed. So yeah, there's just a little bit of nuance there for for my perspective.

Dr. Monica Jain  29:05  

But I think this also then comes back to my earlier point about understanding the processes in the hospital and having someone from the beginning understanding how to develop the product in a way that allows it to be implemented. So yes, there is a natural transition in that way. And then having that that perspective from early on in the development process, then makes your sales cycle that much easier. Because you say that we develop this in a way where we understand all the workflows, and this is the way that it's gonna go in, we're gonna make it super easy for you. And I think that that makes a huge difference.

Maggie Judge  29:40  

Absolutely. So how do you see, you know, thinking of hospital processes and how hospital systems and insurance companies are now leaning more towards just focusing on cost savings, and how that's affect not only products that are the ideas that are coming up now but products that have been working so diligently for the past 10 years to bring something to market and now it's quickly changing and how they can use their product to show the cost savings in the end to help make their products stand out above the others.

Rishad Usmani  30:13  

I think it's a very tough market for founders, as increasing revenue has is really at the forefront. And even reducing expenditure has not looked as favorably anymore. 10 years ago, med tech devices and companies could have a proof of concept and exit. But now they can't anymore. They need a commercialization strategy. And from what I'm seeing, and I'm fairly new in this field, a lot of the buyers and acquires they want products in the market before they will offer

Ruben Osnabrugge  30:47  

depends a little bit on the field, I would say as well. Structural Heart is notorious for early exits. But in general, yeah, totally. And maybe one thing to add on on the reimbursement, health economic aspects, I think it's, I think a lot of funds really double down on that, because we all know, there's two big problems in healthcare, it's a shortage of stuff. Actually the most important one, I would say, but then also the costs in health care. And so you cannot commit innovation that just increases the costs. So in our fund is called the Health economic fund, every investment we make, we do a whole analysis on the impact on on the health economic scenario. So from the hospital, from the society from for the individual clinician, I think is essential.

Matthew Savary  31:31  

So I just want to ask the panel about this and possibly the rest of the room. Because I've heard this pretty consistent story about the narrowing margins within healthcare and the need to make a better health economic story. But at the same time, when we've had conversations about the adoption of surgical robots, I get a lot of hand waving, I would, oh, it's just $2 million a year. That's even that's less than that surgeon salary, so I don't even worry about it. And that's from like the CFOs, or like a value analysis committee leaders that I've spoken with. So how do we reconcile those two things? Because those are two completely different stories.

Dr. Monica Jain  32:09  

Well, so I think that depends on who you talk to, right. So surgery, surgery in general drives revenue in a hospital, you know, it's not the ICU, it's not the medical patients on medical floors, where they're being treated for pneumonia in house or something like that. It's surgery. So when surgery drives revenue, anything that you can do to increase your surgical volumes, and be attractive to a patient who will then come to your hospital for surgery is where you will invest. And so that is all about driving revenue for the hospital, which is what you need. The other benefit is talking specifically about robots comes down to the decreased staffing needs with a robot like you don't have to staff residents with someone who's on the robot or an assistant or something like that. And I've heard some great arguments for value add for surgeons, especially in community in rural areas where they're able to operate with a robot without needing an additional assistant at the bedside that the hospital then has to supply and things like that. And so I do think that, you know, it's still within the same realm of hospitals are trying to drive revenue. And then, you know, eventually we'll be decreasing costs, but this is how they see that as an investment. Going back to your question, I think that from the clinical perspective, it depends on what type of clinician you are. So if you are employed by a health system, and you are like seeing patients, like say, You're a hospitalist and a health system, probably you don't interact very much with billing, you all of your stuff goes all of whatever you do goes to the billing department and that health system, and the billing department kind of takes care of everything. Whereas if you are a private practice physician, you have a full understanding of what billing means, and understand what reimburses better and how to up bill for whatever you're doing. And so I think that there is a different understanding amongst different clinicians as to what gets reimbursed, what doesn't, how to build properly, and then kind of understanding that aspect of the business. And so I actually do think that there are a lot of clinician founders who don't understand that reimbursement strategy, even though they're in the medical world, like they just don't get it. And so that's again, another area where engaging experts really helps. But there's a wide range of expertise when it comes to clinicians and understanding billing and reimbursement and value and all of those aspects of care.

Maggie Judge  34:47  

I'm not even sure of hospitals and insurance company billers understand how the reimbursement and everything works. So to understand it from that perspective, especially when you're when you're a physician and you have a billing team that As it you don't see it, but it really is such a driver. And to kind of jump back, because the previous company I was with, we were in the robotics space. And so I think a lot of times they can say we can we can spend, you know, $2 million on this on this robotic piece here because you're helping retain surgeons because they do bring revenue, and instead of them leaving and going to an ASC because they don't want to, you know, have to deal with all of the rules that the hospital system is putting on them, they can make more revenue, open their ASC through through a hospital system. But now they have to incur the cost of buying a DaVinci for millions of dollars. So hospitals are kind of moving that way. And it's also marketing. So I'm in Houston, where I believe we have more hospitals per capita than any other city in the country. And so we're there's billboards everywhere. You're continuously competing, if my insurance, can I can use it any hospital, why are you going to choose me? It's because of that surgeon. And I have a friend who have that surgery, and she recommended this surgeon so it's not necessarily the hospital. But you're like I saw that thing and see billboard with that fancy machine that I don't know anything about. So they kind of help with those costs that way. So it's it's more than just the cost. It's what does it bring to, which is exciting. I'd love to hear your thoughts and how you see that within companies and how that goes into their go to market strategy.

Rishad Usmani  36:29  

I'll just say something about marketing in general. And I think it really pulling on the scarcity, and the principles of marketing, scarcity, urgency, reciprocity, as a really strong force. And if you can say we are the only hospital in this region with this device that really pulls on that scarcity mindset.

Ruben Osnabrugge  36:54  

Yeah, well, I think the robotics topic is very interesting, we can discuss it a lot. But if I if I may, I just have a question. I'm being the only European here on the panel. What I always admired in the US that there are indeed a lot of clinicians who go the entrepreneurial route. So what is the reason that there's more spark there to do it? I really see it. In the in the Netherlands, there's only a few clinicians who want to take the risk and want to do it, is it? Are you incentivized to do it? Are your mentors doing it? Or yeah, how

Dr. Monica Jain  37:22  

Our system is really broken. Like, that's a whole other panel or two? Yeah, that's what I would say is our system was very broken, there are a lot of problems. And there are a lot of problems that we think that we can solve better than what's happening right now. So I think that that's where a lot of that entrepreneurial drive comes from.

Dr. Qasim Butt  37:43  

And I'm sorry, I was gonna say in the US, like, there's different entry points to attack problems, too. We have different states Medicaid, Medicare, different Blue Cross Blue Shield, Medicare Advantage plan. So your entry point is not one giant bureaucracy of a country, it's various, you could have various entry points to get into, I think that actually causes maybe more innovation or creativity in that respect.

Rishad Usmani  38:05  

To to Monica's point, most of us are running away from clinical medicine, not running towards entrepreneurship. Yeah. But over time, it does change to an extent. And I think it's important to lean into your strengths.

Maggie Judge  38:18  

Well, I know we have these MCOs and ACOs, that they're basically like the mob, the insurance companies pay them to make sure that we do everything that they want us to do. So they kind of take away our autonomy and our thinking, to where now, instead of treating a patient, we just have a checklist. And we have to go through and ask all these questions. And we're checking that off. And that's not why we got into medicine. We got here because we wanted to make a difference. We wanted to help people. And when you just become you just feel like another person you're not you're not special. They give you the stale pizza from the kitchen to say thank you Nurses Week, you know, you don't feel important. And when you watch patients suffered day after day, because of the inadequacies of the system, you get inspired to say, You know what, I can't take any more and I'm going to make a difference. I'm going to go out there and I'm going to die trying. 

Matthew Savary  39:11  

To flip it onto a positive note. I thought that was positive a good fraction of the the impetus is that it's just rad, I have a really awesome job. And I don't think that there's as much exposure to that in Europe because we have a more dynamic startup ecosystem out here. And so you can see people who are getting out there and getting to do these different kinds of things, getting to see new technology, new procedures and stuff like that. So if you have a motor in your chest and you live inside the United States, then you look out there and you're like this new life is possible.

Maggie Judge  39:43  

The Final Frontier, we are in our last minute, and is there any other questions anyone has or a little piece of advice you would like to bestow on our audience or each other?

Dr. Monica Jain  40:05  

Well, that's it. That's a loaded question. So I think it comes back to our discussion about the value add. So on one hand demonstrating how big the problem is, and how much it affects the system, either through money, which is the easy way, but also with time, with the number of resources that are being used or things along those lines. And so it's really understanding the value that's associated with the value loss that's associated with the problem and the value add with your solution. And like kind of bringing those two together. And so I don't think that there are any hard metrics in that way. But as a clinician, who kind of looks at these types of problems and understanding like what is a meaningful change, like having, I don't know, having to have one less nurse on a ward actually makes a big difference, for example. And so I think that it it all depends, like it's obviously highly variable, because it depends on your solution. But that's what I would say is like demonstrating the value. 

Yeah, there's a lot of data now out there about the expenses that are associated with loss of a clinician, and the expense that's required in training a new clinician, and also understanding the differences between an expert team and a non expert team when it comes to taking care of patients. And there's actually a lot of data out there about that now. So I agree with you that retention is as important as reducing the amount of staff that's necessary.

Maggie Judge  41:53  

Absolutely. And I don't mean to cut you off, we need another panel after this. But they're going to start playing the Oscar music and it's time to end. But I do say I love that question. And I've always said the most important person in a hospital is the housekeeper because they control the flow of the entire hospital. So when you're sitting in the emergency room, and you get a bed quickly, thank the housekeeper for cleaning that bed and ICU or med surg to get you there. So thank you, everybody so much for your time. And thank you, everybody. We hope this was informative for you and you enjoyed it as much as we could. 

Speaker 7  42:22  

Thank you. Thank you. Thank you.