BoneChat #145 - ASC Robots, Direct-to-Patient Marketing & Ortho Startup Reality

What was the one that you— what was the poll that you had yesterday?

Yeah, so here, I'll pull that up. It's, um, I just threw out some topics and asked people to vote. And this— here's the poll. Here's the results. It's a 1-day poll. So people want to know who's going to win the ASC robotics race. That's because it's just not working right now. You can't sell a refrigerator into an ASC. You know, you're going to have to think surgical is on the right track. It's going to have to be something that's handheld or really small. No markers, you know, registration, registration and all that. It's just, it's not going to work. And nobody knows, nobody knows who's gonna win that. And then the other big topic was selling with fewer reps, basically. Those are the 2 that people don't, aren't interested in business moats for some reason. You would think people, you know, I wanna create a moat that where I don't have to, where I'm not gonna lose my customers. People aren't really interested in that. Which is amazing to me.

I think that's probably maybe the trickiest question of all of them.

It is. It's hard.

As a rep, what is your moat? It's you. It's you as a human being and the service you're providing.

I remember at Wright Medical, we got into the metal-on-metal hip game and we were— us and Stryker launched the first metal-on-metal hips in the US and And we did really good at first and then we lost business and our head of sales figured it out. He says, we're borrowing the customer. He goes, we don't own the customer. We're borrowing them until one of the big 5, you know, can meet their needs with metal and metal and then they just switch. The switching cost was zero.

Yeah.

And so there, there's very few moats that are just sustainable.

Yeah.

I mean, Class 3 PMA IDs are very sustainable, but you, you know, they cost a fortune and there's a lot of, there's a lot of risk with the Class 3. Anyway, that was the poll. Let me stop that.

I think the ASC's one's interesting. But I think it comes to a financial play of who can put the most free systems in there, like a Stryker ASC system, who can figure the financial aspects out of it. So you just place the Makos in there and not have to worry about the cost of it.

Right. Well, the Mako, the Mako's not really— they're the big refrigerator systems, or they're— all they're doing is placing in capital equipment and they're controlling the implant spend.

Yeah.

And I mean, that's all it is. It's a customer capture strategy is all it is.

It's worked well for them.

It's worked really well. It's, and everybody unfortunately works so well that everybody tried to copy the business model.

Yeah.

With Rosa and, you know, everything else. Ah, it's terrible. And we don't need refrigerators.

No, the handheld one's interesting. I don't know, like, you're— I think is doing a good job, but Ortholine, they've not been able to crack the code for some time.

Yeah, Ortholine is tricky. Yeah, it's— I think the— I think robots are gonna be tiny and they're gonna be little cameras on instruments and you're not even gonna notice them.

Yeah.

And they may talk to a headset. And the headsets are gonna get really small. That's where everything has to go for ASCs.

Yeah.

It's also like you had that huge VR push for a long time as well.

And VR is— I kind of, I finally came to the conclusion, it's just, it's good for training, period. You know, if you have a comp— if you have a complicated procedure and, you know, there's like 30, 40, 50 steps, Yeah, you can practice with that. And, but yeah, it's not as good as a wet lab, but it's, it's next best thing.

Yeah, I think there was a push for it. I don't think it ever took off anywhere in other industries as well, but it's curious to see maybe what these new Meta glasses might do for interoperability, you know, even cameras, you know, can you put the camera and be without a huge tower in there, maybe, or smaller towers? I think there's gonna be something interesting coming down that path at one point, especially with these.

I think AR goggles are real. They'll be around forever. But it's just gotta be, it can't, it can't get in the way of the speed of the surgery or the, or add steps.

Yeah.

It's gotta be like landing an airplane. You know, you see artificial lines in the sky and okay, we'll just follow the lines in the sky. Yeah.

The rep one was interesting. How do you sell without 40 reps?

Yeah. So it got me thinking and I'm actually working on an article right now. And I, it's, I think so the title of the article is The Winners Are on the Edges, Stay Out of the Middle. So if you look at a continuum of complexity, on one side, you've got super simple Stupid kits like Arbutus. Arbutus Medical sells a kit where you can do surgery outside the OR.

Yeah.

And it's cheap. There's zero rep involved. It's so simple. And they're killing it. They're like doubling in sales every year. And then, so that's one side. Then the other side, you go way over to like, I use the example of the Globus giant robot thing, uh, the GPS whatever it's called, 1800 whatever it's called.

Yeah.

And, um, that is so complicated and it only does one thing, helps you put pedicle screws in. And, you know, once they place that, they own the customer. And but if you, if you're in the middle of that, if you're just selling implants, you have a few trays, there's so much competition, so much noise. You've either got to be super simple or super complicated with no competition.

So anyway, I'm curious on, in that like implant space, there's, it's just a different widget. Um, Kyle, and I'd actually be curious kind of on your thoughts on this one. At what point can we find a way to make a better bone anchor, a better screw, you know, that truly does differentiate that way? To give a rep a competitive advantage or company competitive advantage that's in the middle, but there's not much there right now. It's all different versions of everyone's same stuff.

Yeah, it's a little different. I mean, you could you could argue Osio is is got you know a non-metal solution that disappears.

Yeah, I have two of those in my knee. Yeah, I do your MRI and they're gone almost. So it's really cool.

So what did what did you? Is it a knee bar?

What I had the knee bar procedure at a insufficiency fracture.

From—

I had that DFO in the oats as well, so I had complications, and then I had an insufficiency fracture on the tibial plateau. So we put the knee bar in.

That— who did Brian Cole do it? Who, who did it?

Uh, Armando Vidal in Vail.

Vail. Wow, that is cool.

It was.

Yeah, it's cool when you see the MRI, you're like, all right, I see the outline a little bit of it, but it's gone almost.

I remember the old days, we didn't like things you couldn't see. They would try to put barium in it so you could see it.

Or the the carbo fix plates that have the outlines. Those are original.

Yeah, you have a little metal buttons or something in it.

Yeah.

Well, who's everybody's in the background? Who's got a who's got a thought? Kyle, you're Eric, Colleen, Patrick. Even Patrick is here.

What does that mean?

You know.

You're not a regular, but it's great to have you.

I'm just always, man, I always want to join and then I'm like something is.

Yeah, it's never a good time, unfortunately. So.

Oh, good.

I'm here.

Yeah.

All right. Did you see the Medardus acquisition of that giant surgical lab in Durrell?

Mark?

Yeah, it's called M-A-R-C. Yeah, yeah, that is a— that's fascinating. They'll probably do a lot of their— for— they'll do a lot of their thumb training there.

Um, yeah, with them a lot. It's great for their international business, huge, where they do all their international training.

Yeah, it's kind of a South American play, isn't it, for them? Because Miami is basically South America, let's face it.

And then you have some of their main consultants right there. I was a MedArtist rep in Doral in Miami.

Really?

Oh, wow.

So it's, it's a great center for them, and it's beautiful there. It's huge.

Yeah, it's like 37, 36 stations, wet lab stations.

Yeah, yeah, it's gonna be an international play for sure.

That's interesting. And they did an interesting thing where they They didn't make it exclusive, so they're gonna, they're gonna outsource when they're not using it. They're gonna sell access, which is really smart.

Yeah, it's— they've got a massive auditorium in there. I, I've done labs in there. We, we watched the Masters in there at one point doing labs, but it is a beautiful center. It's in the middle of just like warehouses in Doral, but it's really, really— it's right next to the airport, which is really nice as well. So you can get in lab and you know, right immediately. Oh, it's not bad.

That's a big play.

Yeah.

Patrick, what's— did Jansen Cole join you?

That's right. Yeah, he's my SVP marketing now. Yes, he is marketing admitted.

Yeah, he's a great— he's one of my favorite people. He He worked for me back in the old days when he was just an engineer, and at Bright Medical, one of—he was always one of the best engineers. And then he went out in the field, and he took over. He carried a bag. I think he had the whole state of Arkansas at one point, and then he came back inside and started doing marketing startups. He's—we had—we had Jansen on. About a year and a half ago on Bone Chat, and he he gave a presentation on how to brand how to brand a a North Peak startup, and it was really well done. So I'm big fan, big Jansen fan. That's good. Good. Yeah, we have to get him back on one day.

Yeah, I'll I'll come on. He's this week. He's he's. Off in Europe for a week of rest. I think I already stressed him out in his first 2 months, but he's also celebrating his 50th this— I think it's tomorrow or the day after tomorrow. So, you know, we're very lucky to have him, you know, and he's just gonna take a little bit of, you know, an additional angle to to really get us Field Orthopaedics to the next level in terms of, you know, our vision and our position as a dedicated hand and wrist orthopaedic company. So yeah, so I'm very excited. He's already had a dramatic impact at ASH last week for us where we went head-to-head with the thumb implant that you referred to, Kerry.

Yeah, with that giant, that hip stem and the thumb.

And, you know, it was just, it was just interesting. The, you know, it's, it always is going to come down to execution, right? And, and we just executed a lot better. And it was very visible during the dueling where, you know, that's a— I don't know if you're aware, but there's a platform basically that you get invited. We had about 400 surgeons. pausing everything at ASH, and they were basically watching, you know, a surgeon that was provided by us talking about GRIPplasty, and then a surgeon that was provided by, by Medartis talking about CareTouch. And, you know, I'm biased, but man, you ask the surgeons, it was, it was a clear, clear statement by us. So it does come down to execution, right?

So, yeah. Well, Jansen's, Jansen's the best. I used to say there was 2 companies that, 2 startups that did the best marketing of anybody. And it was Osio and Ardalan. And Jansen led the Ardalan, you know, branding messaging. He and his social media content was really good. I mean, it was just the best. Good. He did a lot of patient testimonials, and they were just really well done. They looked like a— I remember the one with Jesus, a patient named Jesus. It just looked like a commercial. It looked like a pharmaceutical commercial. They were so well done, and they were genuine, you know. So, right, he'll— I'm sure he'll do that for you.

Oh, absolutely. For us.

Yeah. Yeah. For the team. That's right. And is he still, he's still in Memphis area? Is that right?

No, he's based in Atlanta.

Atlanta.

That's right.

I forgot. Yeah, he moved.

I remember when he moved.

Yeah. Got it.

Is there a direct-to-patient play with what you're doing now? Because I think it's such a cool product. It's, I mean, you've done such a great job marketing to date.

Yeah, just curious.

You start to see more companies try to use direct-to-market, direct-to-patient utilizing AI and proper, you know, writing techniques in there. It's definitely more cost effective as well, but almost can you push the doctor to get the patients to say, why are we not doing this?

Yeah, it's, it's, I mean, it's definitely play. So, so generally speaking, right, any, anywhere where you have the direct, like you have elective surgery direct to, you know, direct-to-patient makes sense. We've seen a massive uptake of the CMC space in terms of patient interest, right? So it's a real balance though, Steve, because we— it can go, it can backfire to, you know, patients are very excited about products and new technologies. But if they work, that's great. But if they don't, they Will be very local as well. So we have seen some of that, you know, around some of these innovations, including the CMC space, you know, where we've seen comments like never again touch, like it's it just didn't deliver on the on the promise, right? And there is there is real in this space, the CMC space. It's really it's really about patient selection, right? You have. you know, 4 stages of arthritis. And if you, you know, don't have the right anatomy, the right bone stock, maybe not the right level of activity, you know, the surgeon ultimately has to make the choice what the best implant is. So it's a fine balance. So we are investing into direct-to-patient, but we're also— we're being really cautious because you can— I don't think it's quite as— As simple and obvious, you know, like like bunions, the way the way lapiplasty did it, right? It's kind of like it's like a bunion is a bunion. There's no degrees of bunions, right? Yeah. But but within the CMC space, it's a little bit more complex. So so some surgeons like it. Some surgeons don't like it at all. Like they don't want patients to pop up and say, "I want X because I've seen it on Facebook," and then and then the surgeon has a discussion. Well. I understand that, but here are the risks. Here are the risks for me as a surgeon. Here are the risks for you as a patient. And by the way, your thumb is not really suitable for this. And then it becomes complicated. And then, you know, we get the backfire. So it's still to be determined, this whole direct-to-patient space. Yeah. I mean, yeah. Yeah, it's very interesting.

Yeah, we, I remember talking about that with Janssen, and he said the key to direct-to-consumer is the patient has to be able to diagnose their problem. And bunion is the easiest thing in the world because it, you can, it hurts and you can see it. Yeah. DMC is a little different because, you know, the base of your thumb, maybe, yeah, maybe it sticks out a little bit. But, and you lose your grip strength, but it's, you're not sure what's going on and your hand hurts. Yeah. It's different and nobody knows what a CMC is. Patients don't know what CMC means, but they know what bunion means.

That's right. So it is really, right? It's quite a complex continuum of care, right? And that's how we, yeah, that's kind of our 2 cents. So we were We definitely have a website. We have, you know, a patient forum. We, you know, we try to display patient stories, but we're at the same time really cautious about, about how to go about it. Yeah, if you, if you have a playbook that works every time, all the time, I'm more than happy to hear about it.

Yeah. Well, is there a, is there a decision tree that you can take a patient through? Like, Question 1, you know, yes or no. Question 2, yes or no. And then they either get pushed over, you're not a candidate, or you are a candidate, and here's the surgeon locator. Does that work?

Yeah, there is. But then again, then you go borderline, you know, diagnosis. And is, you know, that's, that's again very, very cautious. Certainly, you know, there's, there's always conservative treatment like in the hip and the knee space, right? Like alternative treatments, you know, before you you know, you go into surgery. So, you know, and again, every surgeon is very different in their approach, right, across the country. So, yeah, we try to be participating, but not— yeah, it's— yeah, James, in the same thing, maybe this is an opportunity actually for him to present a little bit on that as well, how we're thinking at Field about direct-to-patient. and the continuum of care and how we're, you know, delicately exploring that space to help ultimately the patient's education, right? So, yeah.

Well, one of the things you can do, and Janssen knows this way better than me, is you can do local tests. You can test by zip code. So, yeah, you can try a campaign and where you pick a You know, pick a city, Atlanta or something, and then you can A/B test in Atlanta and nobody else sees it. So it's, yeah, that's, it's pretty cheap to do that.

Yeah, we're doing a little bit of geofencing and—

Yeah, geofencing. Yeah, exactly.

That's what we're doing a little bit. Yeah.

Perfect. Kyle.

I'll just chip in there. I wanna chip into that conversation. A hand surgeon that is doing a CMC operation is very different than a podiatrist. So while the bunion market is— there's 2 big markets, pain relief, all the stuff, there's a lot of correlation, but especially the ego difference between a podiatrist and a hand surgeon is just— we're talking about 3 orders of magnitude difference. So I think, Patrick, you're on the mark to be cautious about Direct to patient with that because I think a hand surgeon is the last human that wants to be told by his patient what he should do for a procedure. The only one superior to that might be a brain surgeon.

Good comment. I remember I was in surgery once and a surgeon was making fun of hand surgeons and he said, when you hold the instrument, you have to hold your little pinky out like that.

Well, it's interesting, right? I mean, you look, I mean, you know, here in Houston, I, you know, drive around regularly, listen to the radio, and, you know, there are tons of surgeons on the radio, you know, first building the story that, you know, knee surgery has been risky and not precise, but, you know, we have now the solution, come and do MAKO surgery, right? So I'm like, Okay, like for the average guy or girl, okay, that might make sense. But I mean, I mean, we know that, we know that, you know, if you look at the joint registries there, there is actually no significant difference between robotic and non-robotic assisted surgery in patient outcomes right now. It narrows down the outliers and the learning curve. But so it's, it's an interesting space. But, you know, marketing is huge here in the US.

So—

So I'm assuming all of you drive a car that was made at some point in the last 10 years. If not, congratulations, you've avoided some of the pitfalls of that. When I— more and more when I think about all these different robotics and enabling technologies, it reminds me of what's happening inside of the automotive space, right? You've got this system where it turns your car off When you're idling and you're at a stop. It's the most annoying feature there is in a car. Thankfully, you can usually turn it off, but it automatically turns on. You got the lane assists that sometimes will violently try and turn you back into a lane, even if you're intentionally changing lanes but you didn't use your blinker. There's my wife's car. She laughs at me and teases me because she says I'm a bad driver, but it shows like a reminder shows up every half an hour that says I should take a break, and it shows a little icon of a coffee cup.

Oh, that's funny.

All of it is so annoying. I don't need any of it. I've probably driven close to 2 million miles in my life. I don't need help from you, car. You do what I tell you to do. Thank you very much. And I feel like most of the robotic stuff is trending in that direction to some degree, where there's, there's a lot of bells and whistles, there's a lot of fanciness to it, and it probably helps sometimes, and it probably helps some people. But does it only help you because you're a terrible driver and you were going to rear-end somebody? And if you weren't a terrible driver, did you really need it? I don't know. It's, uh, it's, it'll be fascinating because we've had this big arc, right? The last 15 years has been this rise, and everybody's doing it in every sector in all these different ways. And every single market cycle that we have in orthopedics, and I suspect across med device, has a decay curve as well. Like, what will the decay curve look like for some of these enabling technologies? Will it be they become a standard of care and it just kind of levels out and continues to grow with the market? Will it be a market correction that says, I don't need all this stuff, this is now a million-dollar piece of space-consuming refrigerator in the OR? I don't know. There's still a lot of money going after it and still a lot of people chasing it. And I— Tiger, you've brought it up before. Patrick, you just mentioned it. Where are the results after all this time? Where is the definitive proof that says if you put this thing in your OR, your patients are better? We should have it by now, and we don't.

I think, Kyle, it's moving toward— obviously, you're not a Tesla driver, right? I'm not one either, by the way. But the stories I hear that you can literally just push drive me there and literally wake up and you're there, right? So I think it's just a precursor of complete autonomous surgery. I mean, That's what I think. But hopefully, I'll be well retired by then and don't have to worry about that.

I think we're 200 years away from that.

200? Wow.

Yes, from removing a human from— I mean, I was in the operating room in Dallas like 2 months ago and it was a midfoot surgery. And, the manipulation that this doctor had to do where he used his middle finger of his left hand to push in the middle of the plantar fascia While pushing with his right hand on the pinky toe while taking a shot while he was leaning on the leg just to get the bones lined up so that his assistant could place a pin exactly right so that they could put a screw through to get a fusion in the midfoot. The idea of being able to create a surgical environment where that level of touch and feel is replaced by Robotics, it's— we're a long ways away from that. Now, if instead we say, well, you know what, that patient doesn't need a foot anymore, let's just cut it off, well, we can be there tomorrow with robotics. But if our, if our, our purpose is complete restoration of function, there is a lot— there's so much art form to it. I think it's gonna take a very, very long time to replicate it.

Yeah, fair enough.

It's very, it's very haptic.

Let's bet 200 years and see who wins in 200 years.

That's exactly— yeah, yes, we'll wager a dollar on it that it'll be worth a nickel in 200 years for sure.

That's funny.

So Kyle, I was at a conference here in Silicon Valley. Gotta kind of qualify it with that. But there was a physician who was part of the speaking panel. And they had an educator, a physician, a business person. And they were talking about their views of AI. AI in their respective industry. And it was really disturbing to me because this physician said, hey, we're only 5 years away from being able to have AI and robotics take over, you know, like 80%, 90% of what a surgeon or a physician does. And that to me is just unacceptable. You know, I wouldn't accept that kind of treatment. And I would hope that most consumers and patients would not.

Interesting.

But there, there are people out there trying to make it happen.

Well, there are people out there trying to make money off the idea that they can make it happen, not necessarily the reality of it.

Yeah, that's true. That's true.

Yeah. Look at it. I don't, I don't, I don't wanna sound like a total Luddite. Like, there is, there, there's something to all of this for sure. But, um, I think there's so much marketing spin to it. But I was at the doctor with my wife a couple days ago, and this doctor was talking about this, a laparoscopic procedure. And he talked about the fact that he likes to use a robot. Now, we're not doing any sort of procedure, not necessary, maybe in a decade. But he started to talk about this robot, and he was making this pitch about how when using the robot, he has all these special tools where he can use electricity to cut instead of a knife. And he has these special little graspers. And I'm not going to mention what industry I'm in. I know that there is not a single thing that he can only use with the robot that he can't use without the robot. I'll just let him kind of go on his thing. But it was funny because he was, he was doing the pitch. He was doing the, because I do this robotic thing, I now can treat you in a way that other doctors cannot. And I thought that was, that was fascinating firsthand experience with that he read the brochure?

I think what's happening is the average age of an orthopedic surgeon now, they grew up playing video games for the first time. When I went, you know, 30 years ago, nobody did that. But you end up playing Call of Duty all day long and you're very, you're very You trust technology and virtual reality and, you know, robots more than your hands sometimes. It gives you a feeling of power.

Well, let me ask you guys what you would think if, because obviously no one's gonna wave a magic wand and all of medicine turns into robots and AI. It's gonna have to start somewhere. Where would you envision the very first orthopedic procedure being done exclusively by something automated without human hands being involved, either as the controller of a robot or the one holding on to some sort of— what's the very first procedure you can think of in our entire space that would be replaceable by a machine, by the T-1000?

You have— but it's happening in the endoscopic space. I mean, I mean, it's quite obvious, right? I mean, it's the da Vinci I mean, as the— I mean, it's creating massive value.

I think Kyle's asking, but you're still using the graspers with them.

No, I know, but the ability to detect tissue colors, you know, like, I think that's probably where— yeah, where it's such a microspace, right? There is, you know, there's— I think that's probably the area. I mean, it's such It's so— interesting. Yeah.

In ortho, you could see something like long bone fractures, you know, being very interesting, being able to properly align, being able to properly— you know, I do think the alignment of the distraction of a longer bone fracture opened, not fully automated at the point, but there, there could be some interesting applications there.

But the problem is, but the fracture is so— I mean, it is so varied, right? I mean, you can— yeah. I mean, you can't even— you can categorize fractures, but every fracture is unique and simple, like different, right?

Yeah.

I just, I don't see it. I don't see that. And then it's also, you know, cost and time, right? I mean, like, you look at distal radius. So I mean, I mean, these guys, that's a 15-minute procedure. Now, what are you gonna go and use a robot and And then looking at, like, it just, I just don't see it, right? I mean, yeah.

A very non-convoluted one, maybe perhaps, like, at what point does, you're right, the risk and the time really make up? It's gonna be more time to dissect everything, right? You're gonna have 4 surgeries going on at once and, you know, a couple different screens. But I just don't fully see it yet in what, at least, you know, the capacities that they're Diagnostics is interesting, especially oncology diagnostics. Blood flow would be nice to be able to have integration and to see perfusion arthroscopically without having to put like an ICDE or not ICDE, like a dye in there would be very interesting. But, you know, if you can have integrated diagnostics into your scope would be nice.

I could see, you know, a near future around intervention cardiology. Yeah. Right. I mean, our— yeah, sorry.

Some of the challenges I think need to be worked out are things like perceived liability. What if something goes wrong and a robot was, you know, intimately involved? You know, how do you kind of parse all that out? So I think that's a field that has to also be clarified as to how that's going to work, because is it a product liability? Is it a process type of problem?

Have any of you ever read the book Blink by Malcolm Gladwell?

Yeah, I have.

Yeah, so Blink, B-L-I-N-K, like blink your eyes. Um, so Gladwell's got the book Outliers, which talks about the 10,000-hour rule, What the Dog Saw, uh, many— it's my, one of my favorite authors. The point of the book Blink is that with human skills and expertise, sometimes it's really hard to explain how good people are at some things. And one of the examples that they give in that book that has always stuck with me, and I think I first read it 15 years ago, is if you have someone who is like an expert in antiquities, let's say Egyptian artifacts, They may be able to look at something and just know that it's a fake. When you can carbon date it, you can test it this way, you can scan it that way, and all the experts that use all their fancy tools tell you, no, this is authentic, a true genuine antiquities expert might just look at it and something about the dust or the way the dirt looks or the way it smells, something that they can't even describe, They can tell you it's a fake, and they are often far more accurate than all of the special scenarios. There's something in there with what, with what doctors do in the orthopedic space that I think is going to be the mountain that is unclimbable, right? You're going to go do a distal radius fracture, and you got a robot that's going to do it for you, and it does it in 30 seconds. But what if there's that one artifact of bone that the MRI didn't quite catch? And the only way that you're gonna know it is if you're the type of doctor that's touched someone's wrist that's been broken 1,000 times, and you've felt the way that their pinky finger moves in your other hand, and you can't quantify it, you can't describe it, it's not in a medical book, but you just know. And then what happens when the robot misses that and it pinches a vessel, and now you have an arm amputation? And then all the robots get thrown in the trash because now— Because now, now we overcorrect and the pendulum swings the other way. So it's that space is, I think, what fascinates me about what happens here is we're trying to take, and I think rightfully so, and automate elements of the procedure. And I think that will persist, but I think humans are gonna be involved essentially forever.

You're spot on because AI cannot do human taste. It can't tell you what looks good, what doesn't look good. So, you know, if you think about it just from a website creative or Our marketing capabilities. It thinks it's doing something right, but it's so far off, and you can easily tell if you're trained on it. So, same thing surgically. You've got what looks good to a good, you know, just a radius fracture here, but you're missing one little piece. I just don't see that coming anytime soon.

That's a different conversation. I am convinced that we are a long way from AI being able to be creative. And that is a completely irreplaceable part of the human condition that AI is— you cannot put that into binary code in any way. In fact, I was playing with that the other day. I'm looking at joining a new startup, and I was trying to think like, all right, what kind of space could they be going in? How could I kind of prompt? What would be the areas that they might be exploring? And I mean, I just prompted Copilot for hours, like, think about this, review that, look at this, think about these trends, consider these companies, and come up with 10 creative things that could be the next area that this company is looking at. And all it could do was simply regurgitate everything that's been thought of before and just be like, well, this company's doing this, so they're probably gonna copy exactly that. I was like, man, you sound like Smith& Nephew.

That's funny.

You're right though, it is hard. I'm gonna— would you mind texting me your email? I've got a good GitHub repository that's gonna help you a little bit with what you were doing though on the research and the design side of it. I think it'd be nice. You just add it directly into your Copilot or whatever you're using.

Sure.

Cool. Yeah, I think another wildcard— we've all been in lots of surgeries where the surgeon has no idea what the bone quality is until they open it up. And sometimes it's mashed potatoes and sometimes it's hard sclerotic bone, and they just, they can't see that on X-ray. Or, you know, so it's, and it changes the surgery. I, you know, You have to call an audible sometimes because the bone's so poor. Hey, Mark, welcome aboard. We're talking about robots in surgery in the future a little bit.

God, I, I hate robots.

We're on the same page, my man.

Well, what you guys remember David Curran, the orthopedic surgeon from Australia?

It was on Yeah, he's a, he was the one with the curvy hip, right?

Yeah, exactly. Exactly. He's got, he's got a hip that dislocates less often. And he is so against robots. And he's done, he's done tons of research, read every paper. And he, he came to the conclusion that there may be an advantage with unicompartmental knees, period. Everything else, the outcomes are worse. Kind of interesting.

Yeah, I mean, that's, I mean, that's what I was referring to the joint registry, right? There's such, you know, difference. I mean, you know, there's certainly, it applies to the outliers, you know, you know, there's the suggestion that it reduces the learning curve. You know, there's also an interesting, interesting statistics in the joint registry that the, the Peak performance of a hip and knee surgeon clinically, they get there at like the age of sort of late 40s, early 50s. I don't remember exactly what age, but it's quite interesting. So it takes them that long to become a real expert. So maybe robotics can, you know, reduce that learning curve, make it get, you know, get them there faster, right? But yeah, yeah, orthopedics. I think, you know, touch wood, it's robots. It's just a, it's just a thing and not a, not a thing.

Yeah, I heard it's, I heard a knee surgeon tell me that it, it's less cognitive load to do a total knee with a robot. So he, he can do more cases per day. And, but that's a really small advantage, you know. I mean, me, I don't, I didn't, first of all, I don't believe him. And second thing is, I think he just likes the cool tools, but that will never pan out in outcomes. What registry are you talking about, Patrick? Is that US or Europe?

No, no, the Australian Joint Registry. It's one of the, was one of the oldest ones right alongside the Swedish and the British. Yeah. So, yeah, it was one of the first ones.

Yeah. Sweden and the UK are the best registries because they nationalize healthcare. It's just Good data.

Did anybody— so, by the way, sorry, I got distracted. And for whatever reason, the link today was not on my calendar invite. I don't know why I had to go back to previous calendars to find it. But did anybody see the Reuters article about how AI is escalating billing and coding? over the past year for medical practices and hospitals. And depending upon whether you're on the insurance side or the payer side or the provider side, you know, gives you a different perspective on that. If you're on the provider side, AI is simply helping you be more efficient and code things that you might have missed. Otherwise, if you're on the insurance side, it's a little more scurrilous in how they look at it. They think you're just— you're cheating a little bit, perhaps, or, you know, upcoding, and you shouldn't be, or something to that effect. I think it's interesting because both sides now are using AI to fight each other, one to deny and one to bill and code more.

Wow.

So it's so interesting. I'm actually— I decided when after I read that to write an article about it for Orthopedics This Week for their technology section.

Excellent.

Yeah, because it fits right in with why I think you should use an AI scribe or an AI-assisted EMR, you know, or practice management system. It just It catches things that you sometimes would miss.

That's, that's really interesting.

Yeah. So anyway, the article was published today. I just was curious if anybody else noticed it.

I did not, but I will definitely dig that up.

Yeah.

I'm glad they reached out to you because Orthopeaks this week needs— they need more, they need better content other than— they write a lot of articles that based on their advertisers, you know, just Need— they need, you know, a boost, but critical thinking is kind of what they, what they need. That's, that's excellent work.

Well, they've asked me to occasionally write an article on either technology or trauma, and, uh, you know, they know how shallow I am, and it's, uh, you know, everything is related to sex, fear, and greed, so I'll make it interesting anyway.

Hopefully it's just greed and not no sex in there somewhere.

But, you know, hey, so here's why I hate robots, Kyle. I, I don't really hate robots, but I invested a pretty good bit into surgical navigation with Eskilab years ago. And because, you know, I flew to Europe, I looked at the numbers and I thought the outcomes would be better. It was just kind of a given. Based on the, you know, the old Army mantra that all information has value, more information to the surgeon in time of surgery. But what I learned was that using surgical navigation slowed them down just enough so that without it, they could do 6 cases, but with it, they could only do 4. So the American surgeon would rather do 6 and not worry about the outcome 20 years down the road. Now, I don't know whether that's true of robots necessarily. I knew— I do know that if I had to have a prostatectomy, I would go to a surgeon that uses robots. Yeah, because the numbers there, you know, for continence and so forth bear out that it's more accurate.

Yep. It's, it's the fine-tuning, right? Is the da Vinci lets you do things like micro, micro dissections that you can't do by hand.

I don't know. I, I, I don't exactly know why, but I know a friend of mine in Spain, Mike O'Neill, who's a kind of a LinkedIn guru. He married a Spanish girl, moved over there, bragged about their medical system, and then had to have prostate surgery but couldn't wait until the vacation season was over. So he had the surgery done without the robot.

Wow.

And so now he's kind of paying for it. Ouch. Yeah, ouch.

Sorry. Wow.

Wow.

But it was free.

Not free, included. Included. That's like the Canadians.

Do you ever— I don't know if you guys ever saw the TED Talk about the Canadian, uh, lady Who she was, she had a lot of money and influence, and she, she goes in to get a hip replacement. And they said, can we— great, we've scheduled you for 18 months away. And she said, what? She goes, my hip is killing me. And so they said, no, 18 months. And so she says, I'm not taking that for an answer. So she gets a job in the flower Department in the hospital. Every time somebody comes in, she says, "What do you do for a living?" And then finally, she got to know a bunch of orthopedic surgeons, and she got she talked herself into the front of the line, and she got her hip done like a month later. But she was yeah, she said, "I'm not gonna hurt for 18 months just because the healthcare system is you know." It's built like that.

Great. We have any Canadians on this panel today?

My wife is Canadian, so I knew—

Well, I'm not going to talk badly about them.

No, it's okay. Don't worry.

When I was in the service, I flew with the Canadians.

Don't tell her that I— don't worry about it. So it's okay. This is recorded.

So, well, I was gonna say I flew with the Canadians. They were, they were great guys, but My story goes back 25 years. I got bumped up to first class on a flight from the West Coast to Atlanta. And the guy sitting next to me was, he kind of looked like a guy out of the Ponderosa, really expensive cowboy boots and Western jacket, cowboy hat, you know, the look, really expensive cowboy look. Okay. Well, it turns out he was from British Columbia. And he was kind of— he was a timber baron, the only way I could say it. Real. And we got to talking about healthcare. I told him I was in the medical business. He said, you know, I guess if I were an American, I'd be a Republican.

Yeah.

But I'm, but I'm a Canadian, and I got to tell you, I love our healthcare system. He said, not for me. He said, I can afford whatever. He said, but I got a lot of sisters. And they're moms and they're, you know, they have babies and they, you know, so forth, and their kids and so forth. And I don't worry about any of them. They can all get medical care. So it gave me an interesting perspective on, on that particular brand of medicine anyway.

But people, people with big money from the Middle East, Asia fly over to the US for their surgeries. You know, and, and, and, and not only that, a lot of the surgeons in Europe did training here, you know, and Asia too. They did their fellowships here. Well, we've got the best system in the world. It just happens to be the least efficient system in the world. That's, that's the problem. We spend more per patient than anybody in the world by far.

Yeah, our medical system is, I think you can correlate it to the NFL. It is the best game to watch, and it's just wreckage and injuries and chaos everywhere. So yeah, you gotta take the good with the bad.

It is the Wild West, and it's all based on incentives. Everybody's doing whatever incentive fits their goals. It's interesting. All right, we got like 9 more minutes. What's, uh, did, did you, did you follow the shoulder course in Vancouver, Kyle?

I did not. Should I have? I mean, I try and follow. I mean, is— I—

the ICS, yeah, was in Vancouver. I don't know, I didn't go. I have no idea what happened there.

But no, I, I, I didn't pay— I pay attention to that whole market, but I try not to, what, worry about meeting by meeting.

Yeah.

If anything came out of it. I have a question for you guys, because in— if you don't mind, um, in the past we've spent many, many conversations talking about the single primary problem that every startup faces universally, and it's money, right? Everybody's first got to get their funding. I'm curious to know from all of you What if that is solved? What is the next most common problem that a med device or an orthopedic startup is going to run into? And I suspect that's a little less universal. Sales. Okay. And that's because of building an infrastructure, mindshare, finding the right people, contracts are a pain in the ass, everybody wants their own territory and says they can overdeliver. What makes sales the hard part?

It's the human, it's the human part. It's, um, like, for example, the best book on war ever written was by the Polish cavalry officer Clausewitz. It's called On War, and he describes the one feature that makes armies good or bad, or, you know, wins armies. He's talking about Napoleon, is something he called friction. And friction is the human component of getting your mules to cross the river Of getting your artillery to the right place at the right time, of getting, you know, the food and supplies and soldiers to the right place, right time. And I always tell people, I said, you know, everybody thinks that's the easy part. If it's so easy, why can't you get your family to church on time? You know, it's just hard to get out the door perfectly because there's all this stuff going on. You're on the way out the door and the 5-year-old has to use the bathroom. But in sales, it's the same thing. It's the human friction that is so hard. I mean, it's— that's what Tiger's game is, finding the right humans for the right spot. I think that's, that's, that's me anyway.

Well, yeah, well, how do you stay top of mind so they want to sell the product? It's such an ongoing battle with the sales team to say, even though this is a fun, sexy product, if it didn't get approved once, How do you continue the relationship with the distribution team to actually make sure that they are selling it and that it is something that's contributing to their income? It's a hard battle.

What about before that? Right. So you've got a long road to get before you have something that you're able to sell. And Patrick, maybe this is a question for you because you've fought this battle for a couple of years here, I think. What if you're not commercial yet? Then what's the next— what's the next biggest problem after funding?

Quality.

Quality. Yeah, quality system, getting that organized, making sure marketing and quality align.

I would, I mean, the only thing, Kyle, I could say, the, I mean, the sales, I was just gonna say, depend, sales is sales getting to, you know, the first $2-3 million and then the scaling process, it's a complete different ballgame. We can talk about that at a different time, but I think it's I don't know whether I'm gonna use the right words, but it's timing to build your infrastructure, right? So like, it's, you know, it's easy, right? You have an idea, you get a few family offices together, you get a prototype, you, if you're lucky, it's a $5-10K, you get quickly, you know, you get quickly approved. But then the infrastructure, right? Suddenly you were like, You know, suppliers if you're an OEM, you know, QARA. Somebody mentioned that this goes into that category. You know, if you're out of Australia, then you suddenly think about, well, how the hell are we gonna import this stuff into the US? And so it's then you need to think about, well, 3PL. I'm like, how are you not gonna be, you know, buying a warehouse anytime soon? So you need now to think about, well, how do you import through logistically, logistics, 3PL? So yeah, so, so I think it goes on the bucket of infrastructure and where do you start? Where do you focus first? It's, yeah, that's, I find that it's kind of immediately after you raise the money, then you have the money and then how do you spend it so that you build the right infrastructure for the next step, right? Because during the due diligence, whether you're probably as soon as you get into the A and the B series, the investors, they look at that big time, right? You know, you, you know, infrastructure is also the right amount of, you know, IP strategy, right? So you can't do it all by yourself, right? So that's, that's how I'm thinking about it. But man, it's, I, it's a book about, it's multiple chapters about infrastructure.

Great answer. I like it.

Systems.

Colin, what about from your perspective?

Who, who did you ask?

Colleen.

You know, um, I tend to agree, you know, um, with Mark a bit in that the things we can't control— I mean, you can get all the money that you needed per your business plan, but there's so many things that as a management team that's outside of your control. And I think sales is one big one. Um, even if it's, you know, the first $2 or $3 million, it's really hard to get those particular customers to, I guess, respond on your timeline.

That's a good point. I, I would offer up a different idea in the middle, um, which is product-market fit. So I, I see so many companies that they don't, they don't spend the time to refine the implant or the instrument system to make it really, really good. They, they go out, they go out to market with a third, with, you know, version C. And remember, remember Wright Medical when we were there, we launched 25 products a year. It was insane. It was a product development factory. But a third of those did well. A third of those were meh. And a third of those were terrible. Nobody ever sold them. And they didn't spend the time for product market fit. They just threw everything against the wall and they saw what was gonna stick. So there's gotta be a, you gotta be able to refine the product. So it just, it's just perfect without becoming a perfectionist. That's, that's the hard part, I think. And if you got a KOL telling you that the product's perfect, it's, it's usually not. I mean, how many times have we seen, you know, companies go down that path? And that's why companies with tons of products do well, like Paragon 28. They have 100 products, and, you know, the minority of those did really well.

I think something along those same lines, Tiger, because I think we kind of fell into this trap at TrackPatch, is you trying to make the product do too much. I mean, there's, you know, for the first iteration and you don't even really know if those features are interesting to the market.

Yeah, you've got to test, you need a feedback loop faster. You need an early feedback loop that you can trust, I think. And that's, it's really hard to do. I don't know, Kyle, you got like 4 answers.

That's awesome. I wrote it all down. Thank you very much.

You know, Tiger, I think—

I gotta run, so, but it's been great. Thanks, Colleen.

Bye, Colleen.

Bye.

I think to your point about the products of perfection and so forth, I think, I think the hard part about the executive role is figuring out which things you can roll with at 90% right and which things you have to wait until it's 100% right. Because there are things that have to be perfect or should be perfect, and there are a lot of other things that if it sort of works, we're good to go.

That's a good point. I don't know, like, like legal stuff and compliance, it's got to be right.

Yeah, perfect is the enemy of good.

Yeah, perfect is the enemy of good. Yeah.

So, Kyle, I was gonna say I have just some confirmation of everything that everyone said. All hitting all at the same time. We, we have good sales in, in Europe, but we're having to hold back because we don't have enough infrastructure.

Oh, wow.

To sell, which, which goes to our infrastructure. We, we need, we need to build more machines. But we can't build enough machines because we don't have the cash. Yeah. So, yeah, those, those 3 things aren't, aren't separate. They're all connected. And, yeah, it'd be nice to solve them.

Cash flow is a big problem for small companies. It's especially if you have, you have a lot of instrument trays and a lot of, a lot of implant sizes that you have to carry. Yeah, it's Well, we're going over, but this has been fun. Yeah, thanks. I'll try to get the link fixed for next week. Thanks, guys.

Thanks a lot, guys.

Take care. Take care. Yo.