BoneChat #53 - Open mic, open topic, open discussion.

So we don't have a speaker today, which is kind of fun. Uh, we— this is open mic, open discussion. We can literally talk about anything we want. And if something's on your mind, if you need help, you got an idea, you're thinking about trends, but let me share— oh, sorry. Elizabeth's already raised her hand. Let me share my, uh, I came up with 13 questions to kind of oil the skids. All right, can everybody see that?

Yep.

Anybody want to start, kick it off, or pick a number?

We can get some of the easy ones out of the way, like number 3.

No. Why isn't it getting easier? I thought it was supposed to get easier. Like, isn't it getting easier?

Class 3?

Yeah, we're supposed to deconstruct the FDA in the next few years.

Yeah.

Yeah. But then they're gonna have no staff to review what they have to review. So Maybe.

That's funny.

I think the Exactech one is fascinating.

Yeah, I mean, does everybody know what happened there? I mean, they— I'll tell you what I know, which is very little. They had chronic packaging recalls, and they had so many that it turned into a class action lawsuit, and the litigators, you know, the ambulance chasers kind of went after the company. And, you know, the private equity group that bought them for $700-something million, and now the company's worth very little. And some of the insiders are buying the company for $85 million. And remains to be seen what's going to come out the other side. But does anybody have any extra information?

I never dug deep into it, but I remember there being a couple of things maybe 18 months or 2 years ago where they were, they were dancing around a proper field action. So there was issues related to their packaging. It was leading to some parts being bad and they pulled some parts back, but then they sent a letter out and told everybody that all their shoulder polyethylene was fine. And then part of that turned out to be wrong. And I think what ended up happening was— because my suspicion is that they tried to minimize the damage, but it just simply put more spotlight on them, and they didn't solve the problem. If they didn't figure out what the problem was properly and then didn't address it aggressively because they were trying to bury their head in the sand— and we've seen that sort of thing in the past. And then once blood is in the water, I mean, I was at I was at DePuy Synthes when the metal metal thing took off and it became an absolute feeding frenzy for the sharks to where essentially lawyers were convincing patients to go to their surgeon and convince them to take out perfectly good functioning hips and revise them so that they could then join a metal metal class action lawsuit. And I imagine that some sort of terrible cascade probably took place with Exactech product too.

Yeah, it's, it's usually, it's usually not the issue, it's the cover-up that gets companies in trouble. Yeah, yeah, that's a good way of saying it. When, when the, uh, lawyers smell blood, it's kind of all over. I left Sulzer Orthopaedics before everything hit the fan in— was that 2000, 2001? With the dirty acetabular cups turned into a billion-dollar class action lawsuit real fast. Okay, Elizabeth's got a hand up, and Cope—

that, we'll leave that to the last. That, Tiger, that's what I mentioned to you, uh, about an hour ago that I was going to talk about. But, uh, let's— that'll— we'll leave that.

All right, Cope.

Well, I was, I was just going to bring in to, to the effect of the, the Exactech. Um, when I— in 1998, Pfizer launched a drug that was a great broad-spectrum antibiotic that we were selling. And, uh, I mean, they, they'd done more research on it. They had something like 15,000 people in clinical trials, phase 3 clinical trials, which was at the time almost unprecedented, the amount of people they had in it. And they still did not pick up on a signal that certain patients who were on this antibiotic at certain time, like, I mean, would actually die from it. Um, and I knew somebody, like, I actually had a physician's assistant that I called on who took it and died from it. Like, we— and, and they pulled it from the market. But what Pfizer did was, I remember we got like an all hands on deck call on like a Tuesday night, be on this call at 7 AM the next morning. And Pfizer basically said to all 4,000 of— I forget how many it was. You're going into every office, you're calling every office, you're telling everybody, stop using it, pull the samples, take it down. We don't— we're not sure what's happened, but under no circumstances is anybody to keep using this until we get to the bottom of it. And, um, and we wanted— like, they wanted to beat the news cycle because they didn't want doctors' offices getting calls from patients and not knowing anything. And they gave us a very specific thing to say, and it was not duck and cover. It was very, we're not sure, this is not something we've seen, so stop using it. And if patients are on it right now, here's what to counsel them. Everything. We, we were on the phone all day long calling doctor's offices all day long for about 2 and a half days because it hit the Wall Street Journal later that day. And every single office— the drug ended up being pulled from the market., it was pulled and it never saw the light of day again. And I remember thinking like, oh yeah, this is the old Johnson Johnson Tylenol. This is how you do it. And, and if anything, like it was horrible in two offices I had to go into because, uh, one, one, I mean this, I mean physician's assistant friend of ours passed away from it. And, um, another, uh, I forget, a relative of somebody in another office passed away from it. And like you can only imagine what that was like going in there. But everybody complimented us and I don't think, because they handled it the right way. And I don't know if that's what Exactech did. I've heard some of the stories. I don't know all the details, but I just think like, if you attack it, um, and own it and eat it, like everybody tends to be, okay, I'm glad you did it. And their respect for you goes up. And I just, uh, but then I've seen some of this and I've seen a lot of stuff, examples of the exact opposite. And it ends up, it just ends up being such a massive problem, such a massive problem.

Yeah. You know, let me double-click on that because that reminds me of, I don't know if Kai was there, but at Wright Medical, we had a metal-on-metal hip that was, had a design flaw. It was the way the cup overhung the head. And we, it was the revision rate was going straight up and Wright Medical recognized it, and they— we hired a private jet, and the CEO Barry Bays, Steve White, or maybe it was Lawrence Ferry back then, they, they literally flew out and saw 30 surgeons in about 18 days in person, and they said, we screwed up. This is what happened. This is the problem, and we're fixing it as fast as we can. This is how You can revise the hip. This, these are, we didn't, they were so appreciative. They, all 30 surgeons continue to use Wright Medical products because they said nobody's ever done that before.

Yeah, Eric.

Hey Tiger, I was just going to mention that if we have a couple of minutes today while we're, while we're doing this, I have a concept I want to run by, by this group and see what they think.

Sure.

Do you have something to share on the screen, or is it verbal?

No, I, I have— it's better with some pictures.

Okay, throw them up. I'm gonna let other people in while you're talking. Here it is. Spinous process fixation.

Got it. Let me—

did it come up as a slideshow?

Yeah. No, it's not. It's just, it's a— we can see it. You don't have to go to full screen.

Cool.

All right. So, so this is, this is old school, you know, traditional hard work kind of thing here. First of all, how many of you are familiar with spinous process fixation in spine? I mean, is everybody?

A little tethering, yeah.

Some, okay. So on the right, this is a one that's on the market currently. The way you use these are instead of pedicle screws, like where you have an inner body implant that's in, the spine is relatively stable. You don't wanna necessarily use pedicle screws, that's overkill. So this provides you enough stability in a less invasive manner than pedicle screws. I think backing up the interbody fusion is a great indication for this, but also I think it can be used in posterior fusions if, the segment is stable enough. Similar to the indication NAS supports for this. Everybody seems to have one of these. All the companies do. They're all multi-handed, multi-instrument type procedures. Unfortunately, if you look at all these, each one of these has dimples on the side. And that's where instruments grab onto these. So you squeeze each, each half separately, kind of like what you see here. This is the Medtronic's old one where you have to have multiple instruments. And then finally, in your— with your third hand, you tighten that set screw. A lot of these are super complex. You have this one that, that's just, you know, this is an engineer's dream. As much mechanisms as you can fit in one implant as possible. And then there's some that claim to be minimally invasive, but this goes straight across laterally. I can't imagine that's, that's, that's better than, you know, tiny incision over spinous processes. Issue with these is they're all flat. Like, like, like you see here, they don't adapt to the anatomy. Spinous processes aren't like you see here. They're more like you see here where, where the, the bottom of the spinous process sort of flares. And also the further anterior you go, you get, you get the flaring of the lamina as well. So concept I have is a multidirectional spinous process plate. You see in here, there's a ball. That ball allows this half to tip. Angulate and go every which direction. Here it is taken apart. This is the ball, looks like a Death Star. It has a spring built into it going this way such that when you push it onto the threaded rod here, it can only go in one direction. So let me show you. Hopefully this movie works. Is it gone? Yes. Okay. So one, one instrument, you grab onto it, bring it over to the spine. Sorry, I had a pedicle screw thing in there. All I had. Done. Just like that. Um, adapts to the anatomy. One-handed. You know, super simple kind of thing. That's the idea.

So that makes sense. So you're solving this, the complexity, and you're solving the anatomic nature.

Yeah.

So what do you want to do with this area?

That's, that's, that's what I'm getting to. So this one's been on my mind for years and years and years. I think that it's cool. I think it works well. Like I said, everybody has one. So I wonder if this, this would replace what, what, you know, some company already has. Here's, here's the first question. I don't know what this all means. This is not my stuff. Different insurance companies have different coverage on this, it appears. Like UnitedHealthcare says, yeah, great, go ahead and use it. Blue Cross Blue Shield says it's experimental and investigational for every indication, which it's odd because, you know, these have been around forever. And then this one, same thing, saying it's experimental. So I don't know if, you know, what this means. And, you know, like I said, every company has one of these. What is the impact of this on what they do, this mishmash of coverage? So that's one of the questions that I have. I don't know if you want to weigh in on that.

I'll lean in on it. Yeah, if, uh, Eric, we should talk afterwards. I have some experience selling these, and, uh, um, and I think one of the things I would— the market on it has, from my understanding, has shrunk, um, because, because of a lack of acceptance from spine surgeons, although some of the market has moved to sort of the interventional pain management, which, eh, but we could have another discussion about that. But you're right, the spinous processes don't look like what they look like on the bone model and you get in there and they tent or they're, yeah. So I like that concept, but, and I would talk to you about, about this, because I, I know the guy that was the number one, um, user of the first one you showed, I think it was, um, was in— is in Delaware, was in Delaware, still is probably their biggest user. And he was part of their whole greenfield— they called it like a greenfield strategy where they went to, uh, orthopedic surgeons who wanted— who did some spine but didn't, didn't want to or didn't like putting in pedicle screws. And, uh, those days have gone away a little bit, but I always felt like there was a patient population that these made sense in. But you had to— like, surgeons were very, and still are very skeptical. They're afraid of over-distraction, lordosis, uh, overlordosis, or, um, overkyphosing patients, which I actually think is, is sort of a little bit of an odd thing. And you always needed a cage in the front. You always, you always needed supplemental anterior column fixation. But we should definitely talk. I could at least find some answers for you if you want to really scratch that itch. I could help you a little bit.

Yeah, perfect. Thanks for sharing.

That's, yeah, in my thinking, it was, you know, as, as, you know, interbody devices progressed and they got that better and better fixation, you know, got, got more and more stable, the need for, you know, rods and screws in the back diminished. But you still needed a little something. And that's, that's where this would, would, would come in. So I don't know how the surgeons feel about, you know, whether they, they just want the, the super stability of the, of the pedicle screws or not.

Got it. Mark Maloney's got something new to talk about. If he could—

he just—

he disappeared.

He's muted. I think he's multitasking.

All right, let me go. Here's the other rub on this. I patented the thing, but I patented it when I was at Medtronic.

Uh-oh.

They're doing nothing with it. They don't even know they have it.

Um, you can, you can, you can get it back.

Well, that would be part of, part of the plan, you know, licensing it or purchasing it or, you know, some, some creative, you know, mechanism for, for me to be able to use this.

You just got to get permission. It's not— they have— they're not incentivized to— for their lawyers to do a lot of work and free it up for you, but it's possible.

Mm-hmm.

I mean, Raymond Cloutier is a great example. I don't know if you know who he is. He was vice president of R&D at Exactech. And he, he, fascinating case. He said, well, I've got to look outside orthopedics because nothing's new. So he started going to general surgery courses and they were doing surgery through the belly button. And so he said, why can't we fuse L5-S1 through the belly button? And, and he patented it. And then, and the patent issued and he said, okay, Exactech, I'm ready to develop this product. Oh, we don't, we're not interested in developing that product. And he said, can I, will you give it back to me? He goes, sure. And they gave it back to him and he quit. And he started a new company called Nova Solutions. Yeah. No, Nova Approach Spine.

Yeah.

That.

You can get, you know, I certainly gave a lot of IP back to surgeons when, when I was at Medtronic. You know, we, we, we purchased it from them, then gave it back to them for free, which didn't make a lot of sense to me, but that's what we did. So yeah, big questions were, you know, do we think that there's a market for this? Is it worth me going after, you know, I'd be doing this on my own, which, which, you know, I don't, I don't have any worries about. I could, you know, I could, I could 510 this thing, get the testing done, no problem. But is, is, is it worth it? And you know, that's, that's what I want to try to—

is the juice worth the squeeze? You've got to figure out a way to test the market acceptance. You know, the, the building the product is easy. You know, it's, it's figuring out market product market fit's always the hard part. Yeah, I'm not smart enough. Other people could help you, probably. Eric, uh, Mark, Mark, you've got something to share? Maloney?

Yeah, but I didn't want to step on Eric. That's a pretty big question he's asking there. Yeah, so, um, Eric, good luck on that.

I—

you've done a lot of work on that. You know, I don't know whether the market's broken or, uh, if there's a need yet, but good luck on finding out. That's a big— that's a big question.

So I mean, it's not super obvious, that's for sure.

Yeah. So what I'm going to talk about is a big question too. The, um, recently, um, a couple of computer scientist PhDs that I helped out a couple of years ago sort of pro bono came to me And these are machine learning, large language model experts. And they came to me and they said, we've developed an AI persona that's a great communicator. We don't know what to do with it. And we thought, we were wondering if you might want to introduce it to the healthcare market. And of course, you know, every meeting I'm on now, one of the questions that somebody always asks the host or the company is how is AI affecting your world? And I happen to be one of those evangelists that thinks that AI is going to affect everything we do, and it's going to move a lot faster than we think it is, because I've seen other technologies, especially digital technologies, you know, whether it be, uh, you know, Google or digital imaging or electronic medical records, uh, you know, kind of creep into the market, and all of a sudden they're just moving at light speed. And then it seems like a year later everybody has it. And I think AI is going to be even faster. So, um, I can't show it to you, but I could let you hear one that I literally programmed just 10 minutes ago. So I was— before this call, I was on a call with a friend of mine who has a company called Glendor. Now, uh, she's a UC Berkeley scientist too, and her— she's a Russian immigrant, and her specialty is machine learning, but her particular advocacy right now is de-identifying data. So if you— she has a special software program that can cleanse or sanitize or de-identify any image packet or document packet or voice packet of PHI. And if you're in the process of monetizing big data like Emory in Atlanta is right now with the US— with the Society of Radiologists, they're selling their image data to them— then this can be something important. So I fed into my AI model just a little bit of information about Glendor, and I gave them a couple of prompts on making a, you know, say I'm going to send a text or an email to a possible user and, uh, see if you can talk to them and book a demo. And this is what came up, and I'm just gonna let you listen to it. So basically it's on my phone, it could be on my computer, but it's on Zoom. I'm in a video meeting. I can't do a Zoom on a Zoom. So it's going to launch here in a minute. There it is, coming up.

Recording in progress. Is my microphone working on your end?

Yes, I hear you.

Hello, I'm Julia, an AI agent. I'm calling today to discuss how Glendor, a medical software company, can benefit from our expertise in data management. I'd like to explore potential opportunities to help you make the most of your data. Do you guys generate a lot of image data in your work, and do you share that data with anyone?

Yeah, we have over 45 million patients. We generate a huge amount of data, but we're not currently doing much with it, I guess, except using it.

That's amazing. With that much data, it's incredible. Do you ever have a need to de-identify the images or documents, for instance, to share them with other parties or use them for research purposes?

Yes, we do. We're interested in creating a data lake, but it needs to be clean.

Creating a data lake with clean data is crucial. Data also has a market value, and if you ever wish to monetize it, then the data would need to be sanitized or de-identified. Glyndwr is a specialist in this. Would you like to learn more about how we can help? I can schedule a call with our CEO Julia to discuss further.

That'd be great, thanks.

You're welcome. What day and time works best for you for a follow-up call with our CEO, Julia?

Uh, how about next Thursday at 3 PM?

Next Thursday at 3 PM works perfectly. I've got everything scheduled for next Thursday at 3 PM with our CEO, Julia. She'll be in touch to discuss how Glendore can help you with de-identifying your data. We're looking forward to it. Have a great day.

Thanks.

All right, so basically, um, she'll talk about anything that you feed a knowledge base into. I mean, I could basically feed her a knowledge base on spinous process and what Eric was just talking about, and she could then become like, you know, a query device, lead generator. You could use it for— you could basically feed into everything about your medical practice on from a customer service perspective so that you wouldn't have to wait through a phone tree. I've only been playing with this for about a week or so. I'm just curious, do you— I'm just curious what you think. I've, I've showed it to a couple people, a few people, uh, about 25% of them say I would never talk to an AI, never. I want a human. Uh, okay, that's cool. Um, and then some people say, well, you know, she mispronounced this, she mispronounced that, or he mispronounced this, he mispronounced that. And I say, okay, that's cool, you know, you could probably teach it, but that's okay. I mean, literally, I did not program that. That was, you know, that was the AI basically taking, uh, a little executive summary and pitching me on Glendor and making a meeting. And we all, you know, one of the recurring themes in BoneChat is lead generation, the challenge of marketing, um, you know, just creating a, an opportunity, branding, getting them, getting the word out. Um, imagine what she could do for, uh, to, for, to, to say, do RFPs. Or create, you know, do the mechanics of a clinical study or, you know, without a lot of work. And I'm just curious about what your reaction is. That's kind of my moment today.

Well, I mean, I think agents— I think that's the future of AI, is everybody can have their own personal agent. Every company is going to have their own personal agent, and that's just going to be ubiquitous. They're going to be everywhere. You're not going to notice it. Um, and they can— they're useful tools. So, and the other thing is they're getting better exponentially. So every month or two they improve by 100%, which is mind-boggling.

So, so if somebody came to you, Tiger, and said, I'm gonna basically, um, because you helped us out a couple years ago, uh, give you the license for this for the healthcare industry, would you take it?

How, what, how broad is that license?

I mean, couple of computer PhDs, probably as broad as I write the contract.

Yeah, so you're asking, is this a business model you should invest in, basically?

Yeah, I guess so.

Yeah, yeah, I think the answer is yes if you find the right niche, but if you try to go too broad, you know, the— you, you're going to lose. You boil the ocean, you lose. You find a tiny little niche, you win. I mean, what are you— what's everybody's thoughts on where could agents be successful? Go ahead, Mauricio.

I think for first thing, don't weaponize it. So don't make it call doctors, and because that's, that's for sure a way not to know. I'm, I'm thinking, so one thing companies are investing, and we We had the presentation the other day on social media and the leads. I just got like 5 emails from different, uh, then, uh, oral and maxillofacial surgery offices across the country asking, can you, can you print me this? Can you print me that? I have a DICOM file from this. So having an agent to guide that so that once you get an inbound lead, having an agent qualify that lead and probably direct them into a workflow, uh, I think it's going to be a very, a very useful case. And the other thing is like clerical work. So, like, if, if an office, if you're working with an ASC or whatever, and they need documentation regarding invoicing or all of that, I think an agent would be very, very useful. That is very time-consuming, and the agent can actually outperform a human in, in most cases. So I would, I would think something like that, like, in, in the, in the belly of the beast where it's painful, have something that whenever, like, whenever central serial processing calls, There's an agent that will always take the call within 2 rings and tell you exactly where your loaner tray is at or where your rep is or when your surgery is going to be scheduled. I see a massive opportunity there.

So you're basically advocating for inbound?

Yeah.

Not outbound, which you kind of sounded like that would be weaponizing it.

Yeah. I mean, I already don't take calls from unknown numbers from other countries in the world that are trying to sell me this and the world and send me 1,000 emails a day. I wouldn't want AI calling me too.

I'm the same way. I don't take anybody's call or read anybody's email unless I know you. And certainly most people are like that. A lot of people are. But what if, what if you got a text that said, hey, Mauricio, this is Tiger, you should listen to this?

Yeah, if Tiger sends it.

Yeah.

If you, if you create a Tiger double. Yeah, I would. I would definitely take Tiger's text seriously.

I think Tiger already did that.

So inbound. Okay, thanks. Well, y'all ruminate on that. I appreciate your time. And the, for the speaker ideas, I'd like to, I'd like to, I'd like to hear one of these days a cognitive or neuroscientist, uh, tell us why we do what we do as entrepreneurs.

That's a good one.

Kind of, you know, dig into your head a little bit.

And if I could add something to that also, maybe the same person or a different person to discuss perhaps the skill of focusing. You know, there's an increasing amount of attention on the subject of focusing, and I think that could benefit everyone.

Wow.

So I have a group that meets every once in a while called the Marcus Aurelius Society. And some of the most fascinating sessions that we've had have been neuroscientists and cognitive scientists in which we get, we, you know, ask some questions, you know, like that, you know, how do be, how do I focus better, uh, you know, why do, why is when the moon is full and the wolfbane grows do I act this way?

Fascinating.

Here, let me, let me show you my clones. I've, since you brought it up, so I've been trying to clone myself for a long time. There's one called Delphi where anybody can, you can feed it blog articles and I've got 4,000 blog articles and you can feed it YouTube and I've got hundreds of YouTube. So it's called Delphi. I don't know if you can see it. That's what it looks like. Start the call, call again. I'm, I'm shouldn't be doing this live like Mark.

I'm Tiger Buford. What is your question?

Alright.

How big is the total hip and total knee business in the United States?

You're diving into a major part of the orthopedic industry here. The total hip and total knee replacement market in the United States is massive. We're talking billions of dollars. These procedures are some of the most common and financially significant in orthopedics. Now, total knee replacements in particular are done in huge numbers each year. But here's the kicker. A lot of these cases might be overtreatment if you consider that only about 17% of patients have arthritis in all 3 compartments of the knee. It's a big business, but also a bit of a blunt instrument approach. The market's growing as people are getting these surgeries at younger ages, but the outcomes aren't always as rosy as you'd hope. It's a complex market.

Anyway, that's enough of that. But so I just trained it on blog articles and YouTube and it, and it kind of has my voice a little bit, which is, it's scary, you know, and it gets better every month. And all it is is a link.

Uh, yeah.

I'm sorry, Tiger. I mean, listen, I, I, I, anybody know the guys from, um, Stephen Flutie Davis from PitchSync? I don't know if you guys— he's got a podcast that he puts out either every day, Pulse, a beat of medtech, something like that. Yeah, completely two fake people having a conversation about things that he's plugged into it in about two, like one minute a day. He rips like three articles. And if I sent it to each one of you and just said, hey, check this out, it's a pretty good podcast to listen to, whatever it is. 80% of you wouldn't, would not know it was AI. Like, and the only reason I realized, because he said, I'm doing this, and I said, send it to me. And I listened to it and I said, I'm not, I'm not sure I would have noticed. I'm not sure I would have known. Um, so he's like, he's generating an entire set of content that he's doing almost nothing. Like, Yeah, I like— if Skynet isn't here yet, to Mauricio's point, I mean, first of all, we just hired Terminator Skynet for Zimmer Biomet, but like, it feels like it's here, like, because we've got multiple Tigers right now. Um, so I don't know, I, I do— I, I haven't used as much of it, Mark, as I should. Because it's, it's more of a habit thing. I haven't gotten like, remember you're like, oh yeah, I'll go to Google and Google will find me everything. And I feel like it's a habit I haven't gotten into because it is going to make so much of this easier for us. I just don't even think of it 90% of the time.

Um, you guys think Google in weeks. I haven't used Google in weeks. I use ChatGPT.

Yeah, really? That's it. That's like, that makes total sense. I just, I'm still Googling.

You know, you know, I was arguing with someone about a contract yesterday, and I fed the contract to ChatGPT, asked the question for the interpretation, and we settled it in 1 second. No lawyers, no lawyer got any fees for that.

I never thought of that.

I love that. Last 2 contracts I've written, I drafted them all in ChatGPT and then trimmed them out, customized them. It was crazy. I mean, I just canceled Rocket Lawyer. And I think Google's in trouble.

Well, I read the other day that they have like 10% of their engineers only work like 5 hours a week, write like 5 lines of code every month, and they get paid hundreds of thousands of dollars for that. So yeah, I think they're in trouble.

Well, and the government's going to break them up anyway. That's going to happen next year. Yeah, it's— so the answer is yes, there's agents are really useful. I think they're going to become ubiquitous. I think they're going to be in the background all the time. Like, you're not going to know that somebody's reading your contract or, you know, answering your call. You're not going to even know it.

So Delphi, is that— are you— is that connected to ChatGPT, or, uh, it's—

it— so yeah, it just uses the ChatGPT, um, large language model is all it does. And you can feed it in personalized And it's like $9 a month, something like that.

It's incredible.

I put the— I, I put it in the, the chat. Um, yeah, it's this— it's here. I mean, you're asking the right question, Mark. It— I mean, it's real early days, but everybody can see the power.

Oh yeah, it's real early. It's real early.

But it's—

the question is, what is the application for us as medical entrepreneurs? What— where's, where's the puck going in the next year or two?

See, my instinct was it— and I'm glad, I'm really glad I asked, because my instinct was, like it always is, to just attack, you know, just go, you know, which is not always the smartest move, as I've learned many times. But I think— which is outbound. But I think the inbound is— which there's a, there's a big cost to that too. There's a personal cost to that. Those people cost money. That's, that's probably good advice. I have another speaker idea. So I recently met a guy, uh, this geeky little psychologist fellow, uh, in New York, uh, that if he listens to you for a minute, he'll tell you your personality profile, or he'll— it's, it's like, it's like DISC or something like that. It says You know, my master's program at USC was in, was in, uh, behavioral assessment. So I'm listening to this going, are you kidding? He said, yeah. So he did it for me and it was just spot on. Uh, and so if he's, he has a recording of your voice, so you know how Striker and some people, they always, you know, you get a, you go through a behavioral personality profile.

Gallup.

Yeah.

Some, some headhunters, some headhunters use it. So you could incorporate this, for example, into your, into your business. All you'd need is like 1 minute of the, of somebody's voice. And then you could— and you would now have the, uh, analysis of their personality profile. That's pretty scary.

Briggs Myers is dead.

Wow.

He'd be a good speaker.

Yeah. What's his name? Well, you just said it to me later. If—

yeah, because I know the name of his, uh, little company is Echo, but it's not spelled like Echo. Okay, but I will, uh, I'll make a note.

Wow, you're blowing our minds, Mark, as usual. Elizabeth, what are you thinking?

Um, let's come— let's put the list back up there, please.

Okay, I can do that.

Let's see.

Oh, hang on. I think I can do that. Okay, I'm not the greatest admin person, obviously.

Hang on, share.

You had some really good questions on there, some scary ones.

Okay, there it is.

So if someone is, is feeling particularly strongly about discussing one of these, feel free. If not, I'll pick one. I like number 1. In general, what is getting easier? What is getting harder?

Landscape overview.

And, and what, you know, I talk to so many people every, every week that I keep hearing, for my perspective is Sales is getting harder, value analysis is getting harder, FDA is getting harder. I mean, those are just slam dunks. And what's getting easier is designing products, like doing more with less employees, like Mark just showed us, um, contracts, attorneys, legal. I mean, all the All, all that stuff is easy now. You can start a business in 2 seconds now. You don't have to have an office nowadays. I mean, there's so many— creating a business is easier in general. Selling is harder in general.

What would you say is making selling that much harder?

I'm going to defer to the experts here.

Cope?

Yeah, it's the, uh, It's multiple people on the decision-making process, and I, I'd love to hear— I always love hearing Mark Maloney's opinion on damn near anything, but especially on this. But I know I was trained that if I got— and I spent the first 20 years of my career getting clinicians to like, want, need, prescribe Schedule my product, and it was the pinnacle of med device sales. And, uh, now it's, um, it's almost the starting blocks, it seems like, um, any, any more. I think it is the starting blocks, and that's just, that's just changed so much and so rapidly. And, uh That's what I, that's what I sense. I mean, the DMs I get on LinkedIn of people who are furious and frustrated and, and actually good salespeople, right? In the, in the traditional sense, I'm, I'm actually astounded by it. And, uh, um, that's what's made it difficult is the end user has, the end user is no longer the decision maker, the sole, solely. In most cases. I don't know, Mark, what do you think? How do you— you look at it so interestingly.

Well, I think number one, what's getting harder, I think, is basically what Elizabeth said earlier, and that's the focus.

Because of all the noise out there?

It's because— I mean, it, it depends on what kind of brain you have, I think. But my problem in focusing is just, you know, a lifelong insatiable curiosity about everything that comes along. I have a really hard time picking which shiny object I want to shine today. And but there's just a huge amount of noise. And I think in sales, my personal career in market making has been not so much about the product or the service, is finding the early adopter Finding the person that really wants to be different, really wants to, really is ambitious, really, you know, wants to be separate from the crowd, really has a, a reason to run faster or be better, make more money, and then introducing that into that relationship, a way for them to do it, which might be a new hip or a knee or a spine, you know, whatever, you know, in the business we're in. And I just think life now is— life in general now is so easy. There's never been an easier time to be a human. Even our homeless are fat. Most of our clients make more money than they can spend, it seems. And so I don't know that it's just— I think it's, to me, it's almost harder to— it's harder to find the hungry ones, you know, than it used to be. So, but There's so many, there's so many re— there's so many ways to distinguish that. I still think what I look for is somebody that wants to make a difference. We, you know, you and I also run an orthopedic distributorship and I basically just go, I don't go to the OR or anything, but I go to dinners. And we recently found a young doctor that I could tell, I spotted him a mile away out of the herd. He, you know, he wants to be the guy on top of the hill someday. He was like Bill Ritchie when I enlisted him in 2001, you know, in St. Louis, who eventually became president of the academy. Anyway, that's my answer. Find people, find the, find the, find the ones that want to be somebody and then feed them a prop.

You know, I was, I was listening and I think it's, um, it's a little bit of that, but more so of trying to really define who you're, who you wanna talk to and what your message is. There is so much out there and it comes from every, every way, shape, or form. Um, it's no longer where you sit down at your emails and, or you get a phone call. It's coming from Your, your web browsing is coming from social media, your text, and a lot of times, and if it's AI generated in particular, it's what they want to tell you about their product. It's more about them. It's more about a flash, a touchpoint versus reaching out to the right person with the right message at the time that they're going to be most receptive. Receptive. Um, the sheer amount of volume doesn't get it done anymore. It has to be more tailored. It has to be more precise. It has to be more meaningful to break through some of that clutter.

Yeah, I think you have to speak to people's needs, and it's so hard to do that when you've got, you know, 1,000 possible customers. But you have to speak to each person and what problem are you solving? Why should I spend 10 seconds talking to you? It's a hard thing to do.

All right. It's really going to vary from person to person. What do they think is sufficiently important? You know, how do they make their decisions? You know, even down to what they're going through in their lives at that point.

Yeah, well, one, one thing that we've been trying in TechFit, and it's, it's like talking to a name and a last name. So like when we publish something, like we have the person in mind that we want to see that post. So if we met a surgeon in California that does this case and he commented this problem, we're like, we're, we're, we're speaking to him. It's like all a subtext to one person, and there's a likelihood that the people that are adjacent to that profile will resonate with that message too. But it's also like hyper-targeted. Like think of one person and also for our sales plans and everything, we're starting to add like a doctor name to every case we put on our forecast. Like, hey, this is like, we are, it's, it's being like a name and a last name and we're targeting specific people because we, we felt like a shotgun approach where we just threw a message out there and threw things. It was just too ineffective. Like it's, it brings in a lot of junk, and then you have to filter through that junk, and it costs— it's almost more effort than just saying, hey, I'm going for, you know, Peter Jones in Loma Linda, California, and I know he has a residence. So if I'm able to target Dr. Jones, I can build from there.

How do you do that, Mauricio? Do you— is that manually? You write to each person, or do you use CRM?

So we have a CRM, like our, our disrupt gives us an automatic CRM because we already know what surgeons are doing, what cases and how they like to do them. And we have a lot of data on them, but it's also having a lot of conversations. I mean, I've been traveling a lot lately trying to like understand these people that are our buyer personas. And then it gives us a lot of insights to talk to. So whenever I meet a guy, we can already like qualify them.

Okay.

He's, he's a, he's just like Dr. X and I'm sure. Whatever I tell Dr. X that makes him tick will make Dr. Y tick too. So it helps us build like some profiles of like the archetypical surgeons that we want to target and the archetypical people in general.

Interesting.

Yeah, I want to, I want to ask question 8. Can a startup focused on selling only to ASCs? Because I, I talk to startups every week and they're trying to sell to everybody, and sometimes their product does way better in a hospital, sometimes their product does way better in a surgery center. Can you make a living? Can you target and make a living with ASCs?

That's a really good question, and I'm actually generating about 6 proposals now only for independently owned ASCs, this new French sports medicine line, and just pulling in data from AcuityMD of what they're using now and basically saying, I can save you $800,000 if you'll look at this product line.

Wow.

And so far, the first 2 proposals I've sent, I've sent out have been met with deafening silence. It's only been a week, um, and I guess, you know, I mean, you— I still— you still have the same problems of getting through the, the, you know, the noise barrier, I suppose, with there with anything else. But still, that's a good— I'll, I'll let you know. I'm running an experiment.

Cool.

Okay, Cope, I was going to ask, uh, Mark a little bit, but the group There's a difference between can startups sell only to ASCs or should they start— like, should that— like, Tiger, you and I were talking the other day, should that be your Uber Black car, right? And, uh, and I don't, I, I don't know the answer to that, but I, I depends on the, the market size in ASCs now in orthopedics is such that it is its own. It seems to me to be its— as its own expanding universe, um, and big enough that you could probably sustain life there, um, I would think, right? And, uh, but, uh, but I do, I do wonder sometimes if people think that's all they need to do and they don't have to worry about hospitals are too hard, or I don't know, I don't know, but The, the numbers seem to support startups in it. And I think it's okay to be, um, cornered and just like, oh, they're just the ASC company for now. Cause I think people worry about that too much. I think it's a good place to start and maybe you can make a living there and you don't need to go bash your head on some other place. But, um, you can always change your perception. But you need to be hyper-focused and, uh, you know, like Mark, like that's, you might be able to run a business on those independent ASCs. Do you think you could? Like, is that, I know you're experimenting, but if you got what you were getting or think you're gonna get, could you?

Absolutely.

Huge. It would be huge. The, uh, the big advantage is there's no VAT committee.

That's the big— you're talking to the owners, not, not a bureaucracy.

Yep.

Hey, Chris Wright's got a hand up.

I was gonna say, uh, you know, Tiger, you and I talked about that startup that I'm helping stand up right now with that, that gel for adhesion barrier. And, you know, I've, I've been running now for 18 months, enough data to support our launch just on 15 customers and 60% of them do better than 80% of their business in an ASC. So we're, we're gonna be solely focused on the ASC to start with the hand, with the exception of 4 that we're gonna have to do some stuff like at Mayo Clinic or Houston Methodist. But yeah, I think it is. I think definitely there's, you could survive an ASC.

Could be a strength. And we struck a nerve. So Mauricio, then Christine, and then Elizabeth.

Yeah, I think yes. I think you, as a founder, you always have to try to find, and this is something that's very easy to say, very hard to do, find the free markets where you can sell your product, especially in the early stages. I think bureaucracy is the cancer of free markets. So the more bureaucracy, the less free the market's gonna be, and the more hoops you're gonna have to jump through, and the more the players in the bureaucratic markets or the bureaucratic corporations and the bureaucratic hospital systems go like work with each other to lock everybody else out because they want to keep their bureaucracy status quo. But, uh, so I think yes, and I think especially the, the least differentiated your product is compared to existing offerings, the more you have to build a business model that is reliant on ASCs. So you have to be conscious of your— if you're, if you're just, uh, adding an extra widget to, to an existing procedure You have to be very focused on free markets where you can, where you can, where very small gaps can cut, where decision-making for changing is easy. And you have to make sure you find economic sourcing and everything so that your business model works. But yeah, I've been talking to different European companies and their cost structures make it completely feasible to have a fully ASC model in the U.S. If you're, if you're making locally, and you have a very strong sales force, that starts offsetting. But if you go to an ASE and you offer savings and that's your premise and you manufacture in Europe, for instance, I think you can get a big business model out of that.

That's my motto on this: European quality at Chinese prices.

There's the marketing. Christine?

I do agree. I do think you could have a business at ASCs. And I think you could even go more granular than that, looking at the type of ASC and how big and small and what best fits your business model. I think it goes back to, again, the targeting of your product to those that have a need for it, and then really understanding how many you need. And how many, meaning how many customers do you need and how often they have to use. I've, there's been many successful businesses that have started at a, you know, in a smaller market where they can dominate and actually tailor, tailor their service and tailor their product and their approach to that marketplace and then grown it from there. So I like the idea of being more focused and more strategic in deciding who your early adopters, your early tribes, going to be, and then expanding from there. And ASCs, I think, are the perfect opportunity to do that.

Excellent. Okay, Elizabeth, bring us home.

Well, uh, Tiger gave me permission to do this, so as many of you know, I'm a psychotherapist turned writer, um, and I tend to live at the intersection of laughter and tears. And so my business, I'm sending it through a It's live as of last week, Misery Loves Comedy. So it is, it's basically fun, fun lifestyle products for, you know, everything from dealing with teenagers, uh, to elder care to just spouses. And it's, uh, it's quite fun. And I'm very happy to say that today I made my first dollar, uh, my, of, out of my creativity purely. So this is a big day. Thank you. Thank you very much. I was also gonna say, How about we do a holiday happy hour bone chat?

We can do that. What, what day? I think next week is Thanksgiving, so that's going to be tough.

Find an Irish pub near here because that's the only thing— that's the only way we'll get Maloney involved.

We can toss around some dates.

Yeah, pass around some dates. I like that.

That would be good. Call it Day Drinking with Friends.

Maybe we'd start a little later, huh?

Everybody go to an Irish pub, open your iPad, and connect from there.

That would be funny. That would be funny. All right, well, thanks guys. This has been great. These are more fun than a boring startup CEO talking about their products. So we'll skip next week unless Elizabeth comes up with a fun time, and then we'll, we'll, we may do a non-3 o'clock Thursday. Uh, we'll see you guys in December.

Thanks, thanks, thanks everybody.

Thanks, good stuff.