BoneChat #57 - 2025 plans and reflection on 2024.

That's good. Well, let's check. Testing, 1, 2, 3. Testing 1, 2, 3. Testing, testing, 1, 2, 3. Output volume. Testing 1-2-3, testing 1-2-3. Test mic. Testing 1-2-3, testing 1-2-3, testing— testing 1-2-3. Testing, 1, 2, 3. Testing, 1, 2, 3. Testing, 1, 2, 3. Testing, 1, 2, 3. This is really loud and this is kind of soft. This is soft and this is loud. Hello, Tiger. Can you hear me? I can hear you, Eric.

Yeah, nice.

Hi, good afternoon.

Good afternoon, Elizabeth. Hey, the whole world's crazy in New Orleans right now.

It's just— yeah, Eric, I'm in New Orleans. Um, uh, yeah, it's, it's terribly sad. I haven't been anywhere near there. I know some people want to go see what's going on, but, um, now I was just reading something in The Atlantic about it actually, and, uh, the author was saying how, you know, maybe the, uh, ISIS wants to consider that it's, you know, it's not picking the right people, or it's run the, run the gamut of its IQ availability, because the guy's bombs said several didn't go off and all this. And anyway, um, but yeah, I mean, I think, you know, it's, it's hard to feel safe when something we use every day is turned into a weapon— a car, you know. Yeah. So I think they need to— so in France and Britain, um, they have deprogramming centers for people who've gotten radicalized, and we might want to consider that here in this country too. Interesting.

Yeah, very interesting. Yes, crazy times. This whole year is going to be crazy, I think.

Hopefully good crazy too.

Yeah, we want some good crazy. Yeah, we got— we got— there's Phil. Hadn't seen him in a while. Happy New Year. You're— oh, you're mute.

I like your hat.

Oh, thanks. My wife got me it. I— this is my bone chat hat, so I just wear every time.

I like it.

Very stylish.

Yeah, you hadn't been around, Phil. You've been busy guy.

I just have been heading my head down. We're trying to get customers.

So, um, totally get it.

We got one.

We're—

we've got a whole bunch of other ones that are then I need money to go get them. So I'm trying to— and it's, it's tough trying to raise money around Christmas. Everyone's preoccupied.

So it's just like recruiting. Nobody, uh, wants to talk to candidates during Christmas. It's kind of quiet.

Yeah. Happy New Year.

Happy New Year, Mark.

Hey, Mark. Happy New Year.

Hey, Phil. Hey, Eric. Hey, Elizabeth.

We're there. Probably going to be a little light today, but, and so I thought we would talk about— we'll, we'll wait 2 or 3 more minutes. I thought we'd talk about 2025 goals and how people approach those and what, what are your goals and, you know, what are you doing differently than 2024 and things like that. I think it'll be interesting discussion.

We'll just take weight loss off the table because, you know, I think past that.

Yeah, we can go personal goals, but I was thinking more like business goals.

Sure.

Yes.

Oh man, I saw a thing on the— I heard a part of a podcast from the New York Times yesterday about instead of saying I'm going to lose weight, I'm going to do something, it seems punitive, you know, like working out, um, or something. It says, he said, try to make it something super positive, like you're gonna find the best gelato in your city and you're gonna have only one. You're gonna, you're gonna have one super special gelato every week, which I'm not sure how that works in losing weight, but it sounded better than I'm gonna give up ice cream.

Yeah, you know, Tim Ferriss always says, if you guys read Tim Ferriss, you need a carrot and a stick. So you need to give yourself, if you, you know, lose weight, you give yourself a pro— a gift. But if you don't meet your goal, then you have to do something that hurts. And he suggests you just, you write a check to the organization that you hate the worst. I read that. Yeah, you give it to a friend and it's like, you know, if you don't like Democrats, you, you write a check to the Democratic National Committee. Or if you don't like Republicans, you do it that way. Or, you know, a cause you don't believe in. And that, they said, that's really stronger than the, than the, the gift, the present.

Interesting.

Anybody have any friends or family down at the Sugar Bowl?

Well, I mean, I, uh, no, I, but I did. My cousin is a nurse practitioner where I'm 10 minutes outside of the city. And so I texted her and I said, hey, I gave her this silly gift for Christmas. I said, oh, did you bring it to, you know, show your coworkers? And she said, no, things are kind of somber around here. One of our staff lost a friend. Oh no.

Um, yeah.

Surprisingly, a large number of locals who were killed, because, you know, we typically think it's more of a touristy thing to be down on Bourbon. But it was kind of interesting to me and funny. The only funny part I could find in it was CNN's trying to explain, you know, because I'm sure most of the people are like, why are people out at 3:15 in the morning? You know, the rest of the country goes to bed, but it's like, not us, you know. Well, I mean, I did, but yeah. A lot of people out, and you— I don't know if you've seen the video of him doing this, but, you know, horrible.

I saw the link to it, but I, I didn't really need to see it.

Yeah, it wasn't anything super graphic. It was just showing how he turned and sped up and got— went around the police car, uh, just, you know. And the governor made a good point. Somebody's like, well, about this, you know, ballast, ballast, whatever, stanchion, and go down any street on any sidewalk to plow people down. I mean, if somebody wants to hurt somebody, they're going to do it.

Yeah, I don't think people— I don't think anybody outside of New Orleans really knows how hard New Orleans parties.

This is true. And they also think it's all of us all the time, which is like, no, real working people live here. And, you know, yeah, we'll go to a couple parades, but once the parade's over, we'll go home. And, you know, um, funny story, I don't know, we should get back to ortho, but a couple years ago I was at a parade party. And so that's always key, right? You have a bathroom, you have your drinks, you have food. And, um, parade stopped, and one of— they all have chaperones, you know, the little teenage kids, and they have chaperones who are escorting the parade. It's usually parents. So this one woman stopped and talked, and she was the chaperone, and she said, oh, it's just crazy when we get down to the Quarter, because, um, she said, we're not even to the Quarter yet, we're still in the residential areas. And my parade party was in a residential area, and she said these people are taking their tops off. And I'm like, hello, this is not the Quarter. If you want to do that, wait until you get in the French Quarter. Okay, these— you see children here, okay, children.

Wow. All right, well, let's, let's kick this off. So we're going to talk about goal setting and 2025. And we can go any direction you guys want. Let me, let me kind of start off with what did you learn in 2024 that wasn't working that you are going to change in 2025?

I'll start. It's, it's with the issue of focus. I, I do not have ADHD, but I get a little charge out of switching back and forth. Like, I'll be working on an article and then I'll say, oh, you know what, I haven't checked my email in a while. Let me do that. You know, and then I get back to the article and I'm like, wait, where was I? Oh, right. And what else do I need to write this article? And it's so, you know, our text comes through or something. So I just want to be more focused in order to not only feel centered, but to get more done.

That's a good one. Yeah, I sometimes put I, I put my phone on airplane mode and I put headphones on when I'm working. I find I get— I can do like 30 minutes straight, you know. So white noise, yeah, 30 minutes is a long time.

Yeah.

What else? Anybody else? What didn't work in 2024?

I can go, Tiger. Reliance on VC funding.

Yeah, the VCs are sitting on their wallets.

Yeah, yes, yeah, we have completely gone away from, uh, even almost like pitching to VCs. If some— if we're connected with somebody and there's a direct correlation there, then, then we'll do it. But otherwise, to raise money in this environment, and I've seen it through a variety of, um, founders in ortho and spine And I know it's not limited to me or my gender because I brought on a business development guy, two actually, and they can't even get funding. So we can have people get it.

Boston women, women get money much more readily in Boston than they do.

That's actually a complete common misnomer. Only 1 to 2% of all available funding in the world globally, and it's proven city by city., in large cities, women only received 1 to 2% of funding in the entire world.

Every, every startup thing that I went to in the Boston community had set-asides for women, 50% of the money or 40%. And that's primarily what they fo— over and over and over again in the Boston, uh, at least in the angel, not in the angel, in, in the initial seed money, there was an enormous, it, it dissuaded me from even going to them anymore. It was, it was focused on Other than things other than the white males.

Yeah, I don't know. I just know what the data says and it correlates again this year and it's been going on for 20 years. So good for Boston for doing that focus, but I don't think it should be gender related at all. I should, but it's hard to translate when, you know, I don't, I also learned not to go to pitch competitions where they're outside of med tech. Because one time I went to one where I, the one that won was just a consumer product for female condoms. And it was like, there was no way in the amount of time allotted in the audience that we could translate the message in to, it was just not possible. And a former CEO of spine, of a spine company, and he's very well known, actually pitched at that same one and he got ripped apart. He was like, these are complete wastes of time. They were just— and the way that I look at things and measure things are outside of me, where, you know, do my same experiences correlate with others? And that's how I measure things because it allows me and it guides me to reflect and change and make modifications. But if I'm experiencing the same things that others, no matter their tenure or positions, are experiencing. It's been an interesting road.

Wow. Well, that's an interesting point. I've heard, go fishing where other people are not fishing. And everybody, if there's a pitch contest, everybody shows up.

Yeah.

Yeah. You want to be fishing in a pond where there's nobody else. That's really interesting.

Yeah, you know, family offices I think are where most people are going now, and that's one-on-ones. But there's so many family offices, and you really have to tug on some heartstrings there. Um, individual investors— we've had a lot of success with people coming to us, actually, just, um, but the problem is, is you can't take physician money if you want to get on GPO contracts. And it's, it's, it's really been locked down very well to prevent founders from, or small startups from succeeding. They, the big companies and the GPOs and hospitals have done a very good job. And if you don't know how to navigate it, you're in trouble.

What do you mean when you say that they've done a very good job of locking—

of keeping startups and small companies out? So for example, like from the funding perspective, if you try to get on GPO contracts, with a big— if you have any investors that are physicians, yes, and that are going to use your products, they will not allow you access. And so, and then, so you can't raise capital through any type of neurosurgeon or spine surgeon, you know, we can't raise capital from for prevention of issues down the line. And then with regards to pricing, if you're not going to get through be able to prove definitively through the value analysis process that you're going to save the hospital money, you're going to work on infection rates, you know, what matters to them. If you don't, if you're not aware of that stuff, you're really in trouble. Um, just because you have a new product doesn't mean it's going to get used.

Yeah, the company that we've been trying to raise funds for that I'm on the board of in Canada, Montreal, their cartilage repair company. And we changed our policy completely of initially going after physician investors to not having any physician investors because of that.

Yep. That's very smart.

It becomes, it becomes a landmine. You know, you, you, you get the money, you, you, you finish out your production or development, you get FDA approval, and then you can't sell.

Yep. And a lot of people don't know this. That's the, that's the really scary part, is people invest so much of their own personal time and money, and, um, and they think that they're doing it right. And if you don't have that experience on that back end, it— you really— I mean, I, I was— I've consulted with companies that did it the wrong way, and It just caused so much hassles, so many hassles.

I had a meeting this morning speaking of things for this year, and, um, it's a typical meeting with AcuityMD or Definitive Healthcare or any of the big macro information companies that think that orthopedic sales reps are going to use that information are going to get on the computer, are going to input that information, and I have to every time spend 30 minutes telling them that has never worked, it's not going to work. And I said, you, you, you don't understand what it's like to be an orthopedic sales rep. I said, you spend all day in the OR and you spend the rest of the day or evening getting ready to go back in the OR. When are you going to spend time inputting information into a CRM? When are you going to spend time targeting You only know 5 doctors. That's your world. I said, you're not really a sales rep. You're a valet.

You're, you're a materials manager.

You're a sports agent. You got like 2 clients.

Yeah.

And it's the business. So think for 2025 to me is how to take, the rich macro ocean of information and translate that or boil that down or distill it down into something that's actually usable at the distributor level.

Couldn't agree more.

I like that. Yeah, I keep the— David Kaye's words keep resonating in my head about you got to make it simple for the customer. You, it's got to— you got to save the customer time. Save them costs, save them labor, and then you've got a fighting chance. But if your product adds complexity, it's just game over, you know.

It truly— that is so true. And that's the sad part of this, is we have all of this technology that could be extraordinary, but if it misses the mark on one thing of the fluidity or the throughput of the sales process and the commercialization process, it is dead. Just one small move.

Interesting.

Should startups go to trade shows in 2025?

That's a great question.

Only to recruit, not to find customers.

Should they get a booth? I don't know. I have a very— but mine's a weird perspective. Sorry to interject so much on this. You know, the North American Spine Society, they adopted me and put me on a committee, and, and now I'm working on a committee for innovation for the North American Spine Society, the first commercial representative in history to do that. So I think it's all about your willingness to think outside the box. I presented, um, the, the CEO of NAS, um, Eric. He reached out to several companies and asked for perspectives on innovation, and he said that I had the strongest responses. And I answered and I offered up if he needs help on this, I would love to be a part, because any physician that's going in with an idea to bring to market there's a lot of mistakes that can be prevented throughout it. And so I think it's just putting yourself in the universe. Um, but I think the costs are so high, and this is something that I'm talking with them. There should be cost per square footage based off of revenues and innovation. Surgeons aren't showing up to these events anymore because there's nothing new to see. Everything comes to them now.

Are you gonna— you— that's a really unique play at NASS, and I— that's— most people aren't creative enough to do that. Are you going to have a booth? Is Illuminate gonna have a booth at NASS next year?

We had one. Yeah, we, we had one last year because we got, um, um, the Robin Young's, you know, the, um, Orthopedics This Week Spine Award, Spine Technology Award. So, but we got that booth at the very last minute, like the week prior, so we were not planning on going. Wow. But I actually— they asked me to speak at NASA. I mean, when does that happen, right? Like, it was very cool.

That's really— hopefully they're serious. They want to hear about small companies and innovation instead of just check a box, you know.

They really do. I've been in almost weekly or biweekly meetings since the end of— since August or September. So it's really cool.

Cool. Interesting. That was a really good question, Mark. Trade shows or not.

Yeah, I had a meeting yesterday. Believe it or not, I had a meeting yesterday on New Year's Day. The company was in town for personal reasons and they wanted to meet, and I said, come on, come to the office, we'll be the only ones in the business park, which we were. And so we had coffee, and that was one of their questions was, what about trade shows? And, uh, I said, well, I said, I, I think for startups, I, I don't think it's worth it.

I agree.

Uh, you know, you spend several thousand for a booth and everything else. I said, should you go? Yes, you should go, but you don't need a badge, you don't need a booth. You need to have certain key targets and buy them dinner or have a wine tasting or something.

Yeah, yeah. Ted Bird did— you remember many weeks ago, Ted Bird did a really nice presentation on how to get the most out of it, and it was all preparation. It was kind of the theme. Don't have a booth, prepare meetings ahead of time. Yeah, stay flexible.

Interesting. The regional ones are really good though, and they're not so cost prohibitive, and you actually get to speak week with physicians. So I've always been, um, as long as you have like 1 or 2 surgeons there that you know, um, and you can be part of dinner events, and it's all about the after hours. I agree with you wholeheartedly, Mark. It's all about the after hours, or even the— a lot of people don't even stay on the floor the whole day. They go out and have breakfast or lunch and coffee and blah blah blah blah blah. But showing up and just presenting yourself, I think, is the biggest, the biggest misnomer. Sometimes you just have to show up and let the universe happen.

Yep. Well said.

So for me this year, I decided, you know, no trade shows except for ones where they, where I have a presentation accepted or an abstract or a poster and just, just letting that kind of decide my fate.

That's smart.

Yeah.

I don't know, but I had to eliminate them somehow because, yeah. And it's interesting, very specific meetings like you're talking about regional, like Spine Society of Australia. We're going to start kicking off sales there. So Figured I'd submit an abstract there and see what happens. But, you know, it's really targeted, like you're talking about.

Yeah, and the small meetings are good because you can actually talk to surgeons and they're not overwhelmed with meetings and alumni stuff. And like, I always thought the POSNA meeting was really good, you know, small pediatric meeting. You could see anybody you wanted to see at POSNA. You could, you could get time with them.

That's good to know, Tiger. Thanks for sharing that.

That's one of my favorite ones. And then people are talking about the OSAP meeting is kind of a good one too. I've heard comments around that.

I think it's cool that Joey is offering at AAOS to allow the commercial side to come into their after-hours event. I thought that was really cool.

Yeah, Joey's breaking— they're breaking the system. I love it. They're challenging everything.

Agreed. I, I love it. I think they're doing a great job. And David Kay is on that too, right?

Yeah, I'm sure he's part of that. I think he is.

Yeah, I like Ira. Yeah, yeah, a long time ago, and he's always been a little kind of out there kind of guy.

I met him, I met him in the late '90s at a WebMD conference when WebMD was just starting. Uh, yeah. And I think he got hired by WebMD in the early days to be their orthopedics.

I didn't know that. That's about when I met him.

I think I met him in '99 in San Diego at a WebMD meeting when they were just building it. Oh, so what are, what are we going to do different this year? Any other than trade shows? Um, I was talking to a startup this morning. I don't want to say who it is, but they're, they're doing very well. They, they have one main product and they got interested in another product and they gave it to their reps and nothing happened because It was a lower ASP. It was more of a— it wasn't a surgery product, it was more of an after-surgery product. And they don't, they don't know what to do, you know. They got— and so I was trying to tell them, why don't you create a separate business model where you sell the other product direct to hospitals or ASCs with no reps? Just click and order, order 10 or 20 at a time, and it costs very little to do that, and we'll kind of see what happens. It's hard for businesses to, to support two different business models at the same time though, I think.

Well, those are two different salespeople too, like, you know, because this is what happened whenever, um, pharmaceutical compounding came in. They tried to get surgical reps to sell in the office, and the only way that they could do it was have outrageous commissions. And once the comm— I mean, I knew people that were getting just $15,000, $20,000 a month mailbox money for compounding cream stuff. And so, um, you know, I mean, for doing nothing, for having one sale up front. But that's really— that's the only way to get people that have, you know, they're totally different sales models. And this is why commercialization of a trauma product, just like one trauma product, tends to fail because you don't think about, well, the competitive reps stay in those ORs all day long. They're not letting any business go. And two, you have to have the inventory there. You can't— you don't— you typically have enough time to order it, and if you do, it's overnight and it's extraordinary shipping charges, you know, like these, you know, that's, that's where companies fail on the back end. They could have a great product and they fail.

Yeah, it's— we've talked about this before, sales is the hardest part now. It used to be innovation and regulatory and all this. It's sales. Yeah, it's Well, let's talk about goals versus process. So this is always a fascinating thing. A lot of people say, okay, I'm going to accomplish these milestones during the year, and, and then, and it rarely works that way. And, and then other people focus on process. If you just continue to work the process, then you're going to meet your goals. It's kind of like the John Wooden principle. You know, he never, at UCLA, never talked about the score or how many baskets. He just practiced passing and shooting. And, you know, anybody focusing on process more? I am. I'm going to really try to streamline processes.

I think you guys hear me right. I always come through a little weird.

We got you, Joe.

I can hear you. Cool. Well, I'm still a little inexperienced whenever it comes to the med device space, but I've learned so much and I'm at a startup and it's given me a lot of opportunity to get exposure to all the different departments, whether it be quality, regulatory, engineering, supply chain, all of it. And it's been great. I've really enjoyed being able to kind of drink from the fire hose in that sense. But something process-wise that I think that I've done in the past years that I've been here is researching solutions to death, where I'll get to, you know, I'll, I'll have a, a problem in front of me, or, you know, a decision that needs to be made, and I'll be 80%, maybe less, 70% confident in where I should go with it. But I won't act on that 80% right away. I'll go ahead and research and I'll dig around. I'll use AI. I'll see what I can do to give me the confidence that I want in making that 80% turn to 90%, 95%, whatever it might be. And then I'll make the decision. But a lot of times it ends up being whatever that initial, you know, whatever my gut choice went with. And then I introduced a bunch of other options that I wanted to research and kind of vet out. And I just kind of spin the wheels and it leads to decision fatigue and you kind of get, you can get burnt out on a lot of different projects pretty quickly using that route where you're trying to maximize every decision and make sure every decision is the correct one. That being said, I don't plan on making, you know, decisions willy-nilly, but one of the processes that I want to improve for myself is you know, make a strong, a strong decision quickly, act on it, and then learn from it if it's the wrong one. And if not, you won't think about it and you'll be able to progress and move projects along much faster.

Yeah, I learned that from my last CEO. He said, you know, I make decisions really fast, and 80% of the time I'm right, 20% of the time I'm wrong. And it turns out most decisions are reversible. You haven't really burn the bridge. And the other thing I learned is he said, just do something. Give yourself 7 days. Just do something. See what happens in a week. And if nothing happens, good, throw it away.

Yeah, there's the old, uh, Danek, uh, you know, advice, and that was, uh, ready, shoot, aim.

Exactly.

Yeah, I think in the writing Right, right applications perhaps, but not all of them.

No, it's definitely important to just act and to move things along. And I do— I think that one of the— maybe this isn't the case at all startups, but something that we see here at Novasource a lot is, you know, we're not— we aren't built on years and years of experience. Uh, we've— we're comprised of people with various backgrounds. Not everyone's familiar with med device. So whenever it comes to decisions in the med device space, we've got quality team that's worked in pharmaceuticals and is familiar with, you know, FDA regulation. But whenever it comes to med device, they're a little bit shaky. So, you know, you need to vet out these decisions. We don't have all the experience to just say, oh, this is how it should be done because this is how it's been done in the past or whatever it might be. So it happens a lot, at least at our startup, where we get caught spinning wheels on decisions and then things don't get done. As quickly as they probably could. And I think that the Bone Chat is an excellent source that we've since joined this past year, which was a good decision in 2024, was to get into that and start being a little bit more active and lean on some of the industry experience that is at our disposal.

Tell, yeah, tell the group what Novasource does, because you guys are, you're a total knee company. But you're doing it differently and I really love what you guys are doing.

Yeah, NovaSource. So right now NovaSource is a total knee and total hip generic. We've got, it's all reusable systems right now. Very efficient. Our knee is only 2 cases, 2 instrument sets. Hip is 3 or 2.5 really 'cause of the reamer. But really wanted to keep the system efficient and in ASCs. So that's, that's what we're working with right now and kind of where we're making sales. But the focus for the past year has been on a disposable complete knee instrument set where it'll go into the OR in pre-formed packages with all of the instruments already assembled. So all of the main components that you're looking for, ankle clamp being a great example, everything's already set up. So the tech, all the tech needs to do is just pull it out. There shouldn't be any sort of like, all right, do I configure it like this? Do I snap this to this one? It's pre-assembled and it's in order of the step of, or in order of the flow of surgery. You look in the top right corner of the package and you're going to see the 3-in-1 drill bit where you start, uh, find the IM canal and follow the package down, taking one instrument out at a time. And then whenever you're done with it, you can dispose of it. So it's, it's designed to be very efficient and as intuitive as possible, um, and then disposable. So then you save on, you know, you get into ASCs that might not have the capability to do autoclaving and whatnot. So that's, that's been the focus of 2024, and we've carried that focus into 2025. We've done about all of the, the product design and prototyping, and now we're kind of, we're going full steam into getting the parts made for validation activities and whatnot and getting the sterilization validation complete. But that's, that's our goal. Our goal is to go ASCs. And like you talked about earlier, Tiger, uh, we want to make things efficient and we want to, we want to make it easier. Uh, we, we don't want to introduce any sort of complexity whenever we go into these new facilities with new reps and new teams. We want to show them that this is a, a improvement to their quality of life and to the, uh, the steps necessary to complete a case. Excellent.

Is it a rep-supported— is your model focused on a rep-supported case or a limited rep, or what's the plan there?

We like the idea of doing repless. It's something that our CEO— I'm the GM here, I'm not running the show by any means, but it's something that our CEO, he continues to kind of to, as he's talking to people across the industry, he's asking that question regularly to figure out, is it something that anyone's going to adopt a repless model like this? So he's trying to kind of get the finger on the pulse there. But for the initial launch, I think it will be rep.

Yeah, but downstream, you make it simple enough and you make it intuitive enough.

Exactly.

It could be something where there's some initial support or sporadic support, but you don't have, uh, the overhead of having a rep stand there for all day for the cases, especially if it's disposable.

I think we're gonna, we're gonna experiment with, uh, with what you had suggested there, like the, the loosely rep, or—

yeah, we, we like to say at Summit, not rep less but less rep.

Yes, there you go. Yeah, where, you know, you have a rep there for the first couple of cases and then After that, the rep's just in charge of the territory, but they're not going to be in the OR for every single case because ideally that won't be needed.

I've got a solution for you that might dovetail that quite nicely.

Okay.

A support standpoint. Anyways, we can talk about it afterwards. I don't want to bore everyone.

That sounds good.

So it's interesting. I got a, I got a call early this afternoon, Joe, of an international company asking me to sit on a panel to talk about total joint surgeries and ASCs and feasibility and different, different ideas and so forth. So, I mean, it's a great, it's a great place to be. And I, I'll tell you a quick Replas story. So I was the first Orthofix dealer in Atlanta.

Yeah.

And 2 years, 2 years later, I'm number 1 rep. For Orthofix, you know, which was run by Biomed at the time. And they said, how, why are you number one? I said, because I'm not at every case. I said, I, I said, my secret is pizza to the 3 to 11 crew that nobody ever pays attention to. And I train the hell out of them so that when those trauma cases come in, I don't have to be there. And the guy who was number 15 or 20 had to be at every case because he didn't train them to be self-sufficient, to be reckless. Yeah. I don't know who in their right mind ever, ever enjoyed standing around watching somebody else have all the fun. Some reps do.

I don't know why. Well, I think for sure. And I think, I mean, I would say it's, it's like that in this occurs in a lot of ASCs or a lot of hospitals with a surgeon and their team. But I know that whenever I go in to cover cases, I don't need— I know that I don't do anything, you know, I'm there as that safeguard, but the, the team knows the instrument system, you know, and that where this is the reusable one, which definitely is more complex than this disposable set that we're designing, but The team knows the system. I just sit there and I can confirm, yeah, you're going to grab the, the blue trial as opposed to the green one. But it's, you know, that's saving a second that they would have deduced by themselves. So yeah, it's— it feels very feasible. But again, I don't know, maybe this is something that is continued to talk about or is continually talked about. Is it something that hospitals will, or ASCs, are they okay to make that jump or are they gonna be concerned that some, you know, one bad thing could occur without a rep in there and then there's confusion and they don't, you know, they're just afraid to—

I think it's inevitable. I think you're really on the right track. Can we go back a minute to the process question?

Yes, all yours.

So when I hear somebody talk about process, uh, what I hear is them talking about, uh, tactical actions, tactical planning on a day-by-day basis, which in the world sometimes of sales, the only thing you can control really are your tactical actions, your plan every day. I'm going to make 10 sales calls, I'm going to make 10 phone calls, I'm going to, you you know, write 10 letters, whatever your daily plan is, is very tactical and very controllable. Okay, the, the, the, the things that really move the needle though, though, are the strategic decisions. And the reason they're so hard is because I think to me they're very high risk because you can only have one, you know, like in 2025 Everybody on this meeting has got to decide what is the one most important thing I can do. Is it, you know, what is it? Funding? Is it, you know, the KOL advisory panel? Is it the big meeting? Is it the new product? You know what, that one thing is going to like really drive the army or push the ocean liner through the ocean or something. And that's kind of why it's so hard, because they're almost two different brains and skill sets to me. Anyway, I, I love that conver— I love that, that topic.

Yeah, that's a really good point. A lot of people just want to be busy because they think they're, they're moving the needle, but they're not. They're just treading water by being busy. I think Alyssa said it really well. Going back to Joe's comment, a lot of reps are in the operating room from a defense standpoint. They feel like they have to defend the territory. And what, like what Joe said, you're the rep's really just a high-priced insurance policy, you know, person sitting in the back of the room with a laser pointer just in case.

Well, I think the reason why Mike was successful is he didn't go extreme, right? And he analyzed it every single day. And that's the problem with the repless model. I pitched a repless model to Mercy Hospitals in 2011 for total joints. And one pro— no matter how low the price got, you couldn't collectively get all surgeons on the same page using the same product. And also the what-ifs came into mind, into play. What if something goes wrong? So until a system is adopted where they have people with technical expertise that can evaluate— honestly, the only way to do that is to be really well-versed in the actual surgeons themselves. And so Mark knew, just like I knew, which surgeons you absolutely had to show up for, right? And that's why a repless model will never work until there's perspective that's gained. And the only way to have that perspective is to have worked with those surgeons. So I think, um, I think you have to get a few highly, highly tenured, or like one highly tenured person in there, just like Mark was and just like I was, that can go, this surgeon you show up for, this case you don't, this blah, blah, blah, blah, blah. And you analyze it every single day. Um, when we did the repless— when Mercy did the repless model for spine, they hired the techs. They paid the techs a bonus, and the techs ran the program, and it failed. It didn't work very well. And, um, I don't— I have theories, um, that I won't voice, but, um, it's interesting. And they changed vendors. They went from I think Medtronic to Stryker and then, and then to another company. But it's just never been super successful. Nobody's ever been fully happy with it.

I think one of the things really affecting it is the preponderance of traveling nurses, traveling surgical technicians, and the only consistent presence in that OR is a rep now. I have a number of surgeons that have invested in my company. Who have alluded to the fact that they don't feel like they have a skin in the game at the hospitals anymore. They're not gonna waste capital in the hospitals. There, a lot of them are associated with surgery centers where they feel invested. Um, and they will, they will work at a surgery center to bring change, but forget it. Um, the faction inside the hospitals is so powerful. Um, you, you've got people on these VAC committees that can, a nurse can torpedo something a surgeon wants. That's enormously frustrating for the surgeons, and they've pretty much thrown up their hands in the hospitals. So faction is a huge problem, but also the fact that the surgeons have checked out on the hospitals. They don't really care. They'd rather waste their political capital at an ASC where they think that they can, they can actually drive change in better process.

And that's a very valid point. I completely agree with you on all fronts. But I should put a disclaimer that these were W-2 scrub techs that worked inside the hospital and worked with these surgeons. Surgeons over and over for years prior. So they knew the surgeons and they did not travel to other hospitals.

They knew that.

Oh yeah, there are situations like that, but I think that the preponderance of travelers has dramatically impacted surgeon enthusiasm for going to a hospital. They get really frustrated.

Yeah, I think you're absolutely right. And both comments are just spot on. I mean, I have a unique perspective that my dad was the administrator of our local hospital and I was, when I was 17, I was a scrub tech. And for the next couple of summers, and everybody thinks, you know, if your dad's a doctor or the administrator, you want to go to med school. I had of course no desire to do that, but I never saw a sales rep in the OR. I saw one, I said, take it back. I saw one, it was a Codman rep. And when years later, when I got out of the Army, when I went to see the headhunter and I mentioned medical sales, he said, why, why are you interested in that? I said, well, I knew one rep that way back when, and he drove a Jaguar, so I must, he must have made good money. So, but there were no, and there were, there was no interchangeable, the, the, the team was the same every day. Of course, it was, you know, 50 years ago.

But yeah, on Tiger's point, it's defensive practice now. That it adds to the other, um, thing that makes it so hard to get in hospitals is they have learned to be defensive. And some surgeons are just not worth, uh, giving up. You know, if they're bringing in a million dollars, just them alone, of revenue, they're— that $100,000 or $200,000 or even $300,000 a year just for that rep to be placed there. Is not worth giving up.

But, but if you're bringing something new and that's an efficient, a greater efficiency to hospital, I don't care.

Yeah, I agree.

They pay lip service to it. Yeah. But they, they getting, getting the change done is so hard. It's, it's just the juice ain't worth the squeeze in a hospital anymore, unfortunately.

I agree. And even in the ASC too, like you walk into KU Medical Center and the cardiology, the, the surgical center over in the— there's a $9 million check from Stryker literally as you check in. I mean, like, because they get a rebate back, right, at the end of the year. So even the, the hospital administration is so protective of the ASC as well. Like, I think it's hospital by hospital, and that's the nuance that is rarely understood. I couldn't agree with you more, Phil, too.

Sales is a local business, even in the same city. Every, every center is different. Every surgeon is different. Yeah.

Wow.

This is breaking down into a sales, less, less sales or, or rep light kind of discussion. I wrote an article on LinkedIn like a week ago about the prickly topic of having reps in the OR. And people went ballistic. I mean, people were insulting me. I mean, you don't understand.

Try being me, Tiger.

Yeah, Phil's trying to actually count all the little implants in the operating room for the first time ever.

Well, one of the things that we're doing is we're bringing a screen to the edge of the OR that's outside of the firewall. So we're using captive enriched master data from our partner to collect every— to capture everything via scanning. But I wanted to bring this up. One of the things that the— our, our member companies right now are interested in doing is surveying the surgeon. Right now they pay the surgeons for surveys, especially if they're going through distributors. They, they really don't have a direct line to the distributors— I mean, to the surgeons. So the OEMs are interested in paying the surgeon for a quick survey at the end of the case where they come over, they Break scrub, come to the screen. It's quantitative. It doesn't get you into regulatory problems, but basically asks your satisfaction with the case, the product, the service. You know, you fill it in and then we provide a quantitative analysis for customers on— and there's a, there's a lot of interest in that because it's, it's right after the case, it's fresh in the surgeon's mind. But what they're also focused on is using that data for marketing. So if there's a surgeon that's unhappy with something, they, they actually know it as opposed to a distributor papering over problems because they just don't want the OEM to know. It's just an interesting dynamic. I think digital content at the edge of the sterile field that's outside the, the, the overbearing presence of that firewall where, where data can flow back and forth from the provider is something that possibly is a wave of the future.

That's where the funding is going from Strategics. Is all is in data.

AI, AI and data, right?

Yep.

Yeah.

I got a break, guys. Thanks very much. I appreciate it, Tiger. You do a great job.

Uh, thanks, Bill.

Happy New Year, everyone, for 2025.

Thanks.

Happy New Year.

All right, go, Sue Mae.

All right.

Thanks, man.

I've adopted, on that note, I've adopted time value of money. How much does this cost me? What's the future benefit? And For example, we had a manufacturer today who asked for a weekly meeting and I go, you know what, all of my people are— I put it like, what would be my hourly wage? What would be theirs? All the people that need to attend. And any time we've had team meetings with manufacturers or vendors, nobody shows up half the time, you know, it gets canceled and blah, blah, blah, blah, blah. And I was like, a meeting in general is good, But it's— if it's going to cost us $700 to do this one meeting and we do it weekly, it doesn't make sense. But what does make sense is have everybody, because we have multiple vendors, everybody on that call. We do it for a month weekly, and at the initial kickoff, everybody's on the same page. We know the throughput, um, from the— from where the screw— the screw manufacturer, the shank manufacturer, the instrument people, the sterilization, the packaging, all of that. Same call, knock it out in 30 minutes to an hour, very fluid. And then we understand how the whole process is, Mark, is operating together. And then we could do side chats. But like, I was getting bombarded with people that said I needed to meet somebody or know somebody. I was working 13, 14, 15 hours a day and not getting my work done because I needed to know somebody. And I've realized focus, like Elizabeth was saying, and tell your daughter hello for me, or happy birthday, side note, but focus is going to be really, really key. Even though I diverted with the, with the daughter comment.

No, I think it's Bezos at Amazon that famously had really short meetings. He had everybody write down a one-page, you know, document of what they wanted to accomplish and, and an agenda. And everybody, you couldn't go to the meeting unless you had read everybody's one-pager. And then the meeting lasts 15 minutes.

Yeah, I adopted a policy, no more strategy, no more strategy discussion. We have discussed strategy And we have 5 backup plans for everything, and we don't know what 6 months from now looks like, right? I'm done with strategy. It's all execution until there's $1 million in the bank account, an extra million in the bank account. Nobody— we're not talking about anything. Nobody is talking to anybody about anything else other than getting what needs to be done, done.

So that kind of goes back to what I was talking about, about the tactical composure. That's the only part you can control.

People love to talk and people love to put opinions on, but nobody likes to do the work.

Yeah. Yeah. Go, go do an experiment for 7 days and tell me what happened. That's, that has value.

Yeah.

But not just talking and talking.

Yeah. I put the, a link in the Instagram, uh, thing that I sent out to the team over the weekend and it said the secret to, um, this on this very successful entrepreneur success was he made at least 2.5 mistakes before people got even started. And so, because you learn so much from the mistakes, right? And it's okay. And people have such a fear factor for mistakes. There are strategic mistakes though that can get you in trouble, and you really want to be preventative of those, like articles and bylaw formation and how people are compensated during the conversions and their shares and those mistakes can— and how many board people that you have— those mistakes can really bite you in the butt big time. And so it's speed is our best, is our best chance of getting ahead. But at the same time, it's very calculated and you really have to trust your team. You have to have highly tenured team that have made a lot of mistakes.

Yeah, I love that. I think product market fit is one of the biggest mistakes companies make. They think their first product is perfect, and it rarely is.

That's—

going back to meetings, I remember the CEO at Ellipse said, he goes, I hate meetings, and if you invite me to a meeting you're fired. I mean, it was like, I mean, he said, we have 4 meetings a year, and those are the, the 4 quality meetings by law that we have to have. If I see any other meeting on my calendar, you're fired. And so it would just— he said, if you need to solve a problem, grab me or somebody else, go in the conference room, solve the problem. We don't have to schedule a meeting for that, you know. We're 20 people in the same tiny office, you know, we, we can all see each other. So it's kind of interesting.

Yeah, that's it. I mean, that, that's awesome when you have— when you all work together. That's the beauty of being able to work together, is that fluidity.

Yeah, there's advantages to be in the same place. There's obviously disadvantages, but there's definitely advantages to be in the same place. Another, another Meeting hack I learned about is never go to a meeting unless there's a detailed agenda. So, because like you said, people just want to talk, but what are we going to talk about and what are the objectives of the meeting? What do we expect to get out of the meeting? And then people know whether or not to attend or cancel a meeting even if it's a bad agenda.

Yeah, agreed.

Agreed. We've been talking about AI tools a lot recently, and Mark and I especially, and I think that's going to be a theme this year. I think small businesses are going to be using more and more AI tools. And so if anybody sees anything really interesting, share it, share it with the team. Another, another thing on BoneChat is Mark has suggested a professional storyteller for medical device companies, and I'm going to have her on, on January 16th, and I think that's going to be really interesting.

But how did you find this person?

Well, every— all roads go back to Mark. You know, he's, he's got such depth and, and, you know, broad exposure that he, he knows something about everything.

So her name is Sarah. Yeah. And, um, she's a very interesting young woman and, uh, her company is called Stories with Substance.

Hmm.

And anyway, so I think you'll enjoy talking to her.

Is it solely focused on med device?

No.

No, she does more than med device, but she, but a lot of healthcare. Yeah.

I think she has a, she has kind of a counseling background. You, you should let it off.

When is she coming?

Next week, you said?

No, this— it'll be 2 weeks, January 16th.

Okay, great.

Hope you make it.

So right after JP Morgan. Is anybody going to JP Morgan?

No, just you.

I, I— yeah, I was plan— I wasn't planning on going at all, and then I, um, had some You know, when, when, when money meetings for opportunities for money present themselves, you show up.

Are you, are you speaking or just networking?

Uh, I have, um, two opportunities to speak, um, but, and then the other one is more, the others are networking. And, um, it's with a VC invited me to a variety of meetings. Uh, there's one that's being co-run, co-run with Stanford in regenerative and AI. That sounds really cool. It's an all-day event. So I'm excited for that one.

So that reminds me, I'm doing a, a, a symposium on February 11th. It's 6:00 PM Eastern. I'll send you all an invitation. I'll send Tiger one. And it's called Using AI in Your Medical Practice. Wonderful. Saving Time and Increasing Efficiency.

Yeah, I'm sure a lot of people just don't know where to start, Mark.

That, well, that's just, that's exactly it. And so I've got several, I've got the chief ortho from Kaiser Permanente. Wow. An ortho CEO of EMR accelerator company, CEO of Scale Healthcare, a couple of other people, two PhD types from UC Berkeley, they're AI you know, computer geeks. And the whole purpose of this is to stare at this AI universe and see, you know, what can a community physician practice, what can a real-world practice do or use this that'll help them save money, make money, see more patients, you know, what, something, something useful.

Yeah, and we'll see where it goes. One AI program that comes to mind is maybe the lowest hanging fruit.

Are you, are you asking me?

Yeah, yeah. Do you, I mean, do you have something in mind as far as what's most accessible for community docs?

Um, the one of the biggest kind of, uh, demons in the physician burnout to conversation is electronic medical record usage, documentation, documentation. Um, because it's— if you screw it up, you get sued. Um, patients die. Uh, you, you know, your world goes to hell, and it's such a burden for them. And so that's a big one. And there's a lot of going on there with ambient scribing and, you know, AI-assisted documentation and so forth and so on. And one of the people on there is Kishore Tiponini. He's a physi— he's an Arizona orthopedic surgeon who has a, who actually wrote one of the first EMRs back in '99, 2000. He has an accelerator program. So he's on there. But, you know, there's going to be a lot of other conversations going on, you know, revenue cycle management, billing and coding. I don't know, I'm just gonna be the host. I'm gonna be the voyeur.

I love it, Mark, you'll be perfect for it.

Yeah, it'll be fun, won't it?

Yeah, you know, it— that's where companies can really help people. I mean, I have, like you, I have a unique perspective. My father was an orthopedic surgeon. My partner was a retina surgeon, you know, like, and all it can— seeing what my father's free time looked like compared to what it does now is totally different. Uh, I mean, my partner is working literally all weekend long to catch up on 120 worth of notes. Oh yeah, it's terrible. It's absolutely terrible. It would be more beneficial just to have a camera in the room. I mean, like, that everything is documented, because your reliance upon what one person says versus the other is— if Fathom was in the room, right, like, Fathom just took the notes, you know. Like, once Fathom gets, gets better, obviously, um, but they do a pretty good job, much better than I think probably is translated from memory 5 days later.

Yeah, we've got to get— so I don't know how many people know Dave McClain. He's a Bone Chat member, and he just joined Clinical AI, and he's, he's basically the CEO of Orthopedics and Spine for that tool. But they've got— I mean, it is— I, I can't wait to get him on here, but they basically, they have, uh, an AI tool that can turn any video into instant scripting, basically. So, and retina surgery is funny, you, you said that, uh, you know, retinal surgery is probably their biggest use right now. So it writes, really? Yeah, it writes. All you need is a video, you need a moving video, and the AI will tell you, okay, that the surgeon just released that ligament. Took 3 seconds. Okay, now that the blood vessels bleeding right here on this anterior side, I mean, just literally, it, it tells you exactly what's going on in words.

They put it, they were on here.

They were, but he's, but he's, he's getting deeper into it. He was a consultant. Now he's getting much deeper and he's looking for orthopedic spine applications.

Next.

Ortho spine is going to be tough. You know, retina is the perfect application because those patients don't keep going to the same doctor, right? And, and so they go there, they see like a trauma surgeon. This would be perfect for trauma, um, somebody where the patient doesn't keep going back and back and this procedure is different for every patient, right? Whereas like a total knee, you have the same cuts, the same releases, blah, blah, blah, blah, blah, unless it's like oncological or revision. But trauma would be a good application.

Yeah, I like that. I like that a lot. And I think he's starting with kind of a, okay, this is what the AI sees, but it's not going to be providing medical device, you know, but I think the surgeons and the OR team will quickly learn that the OR, the device that the AI has given them is actionable. I think they'll quickly see that.

The, the, on the, the legal side, on the back end, is there will be algorithms into place to say that a surgeon missed doing a release, and then the surgeon gets called into court. Why didn't you do this release? And they have to recall from 4 years prior, uh, why they didn't do that specific release, because it didn't— it wasn't, you know, it was already released or something like that. That's where But have you ever seen Dr. Glaucomflecken's version of how to learn the EMR and the ortho? That was so fun.

He's a guy.

Great.

Yeah.

Great.

I love it.

I heard a, I heard a really smart person say that if you're not using AI in medicine in 3 or 4 years, it's gonna be malpractice because the, the AI can do so much, so much faster and more accurately.

Well, I would consider it self-harm, not malpractice. Like, anytime somebody does a bold statement like that, it never comes to fruition almost.

But true.

But, but I mean, it's self-harming. Like, these guys, these women and men are so overburdened. They're so overburdened. It's terrible.

Yes, doctors are making less money doing more work every year.

And they have less opportunity to make money than anybody else.

Yeah. That dissuading of— are we seeing numbers of med school applications down because of that? I haven't heard, obviously.

I would guess it's my— just anecdotally, I would guess it's the same or growing, but a lot of that's international people coming over. I bet American citizens in medical school is probably going down.

Well, yeah, I think I had— I believe that I had read that, that there are less people that are going into medicine in general, um, just because of the burden, but also because schools are not getting grants for diversification anymore. Um, and because it costs money to get into the U.S., um, I think med school in general, the first 4, 4 years, right, or first 6 years depending on the institution, are down. But once you start getting paid and compensated, I bet they're rising in the residency and fellowship programs.

Yeah, I don't know, some doctors come from other countries, they have no idea about what they're facing as far as paperwork and regulation. Because in, you know, and I mean, my ex-husband's from India, you know, in India and a lot of these countries, the regulations aren't as strict. So here it's just it's, you know, suffocating, uh, and they may not be knowing what they're getting into.

Yeah, it's, uh, pretty intense. Like, you have to do a residency typically all over again, even if you have a specialty coming in. But I've heard, I've heard that, um, that the practice of medicine in the U.S. is the best to learn from, is what I've heard. So, um, no matter which country you're from That probably will change. I mean, I could see India really surpassing us, to be honest with you.

They're—

they want it more, right? Like, the peop— the— it's nothing for somebody over in India or Northern Africa to have multiple degrees, a PhD, an MD, and an MBA. You know, they just— they're driven like we were in the US and like in the '50s, '60s, '70s were— and then I think the '80s had kind of a turn.

Um, but yeah, that's when I started hearing about people not wanting to, to go to med school because it was just too burdensome.

Yeah, secret to motivation is deprivation, right?

That is true.

That's a great quote, Mark.

So I was having dinner once, actually in Germany, and there was a— one of the guests was a professor of economics. He was a German guy. And the subject came to American medicine and how much doctors make here. And he went on, he gave me a sort of a little lesson. He said, in every country in the world, he said, the amount of, amount of money you make is based on the amount of value you give your community. And he talked about engineers, university professors, physicians. He said, those three groups throughout most of the world make approximately the same amount of money. Except in the United States. He said you're, you're an anomaly and the market will eventually correct itself. Interesting. That was 20 years ago.

It always does.

Yeah, school teachers, they do a lot of good for the community. They're not well paid. Therapist, psychotherapist.

He said university professors. He didn't say school teachers.

So, right, right.

Yeah, yeah, I agree with you.

I do. We have to do something better for teachers. It's deplorable.

Oh, and therapists too. I mean, I know people in Philadelphia making master's level therapists making $35,000 a year. It's preposterous. And they're saving people's lives and helping people get their lives back on track. Yeah.

So here we go.

I'm going to sign off.

Great discussion, guys.

This is— we've gone over an hour this week. This is fascinating. So we see you guys next week. Yeah, this has been great. Have a great 2025.

We'll do it again.

Hey, Mark, who's the audience for your symposium?

Good question. Um, physicians, commu— uh, I want working doctors that run medical practices, small to medium-sized practices. You know, I run a regulatory compliance company called VenOps for hundreds of medical practices. The, uh, our average client is a big practice with its lawyered up, and they take care of their doctors. But the average small to medium-sized practice, nobody takes care of them. I mean, they worry about basically somebody quitting because it's so hard to rehire a good receptionist. And so I want to help that group, and, uh, if I can. So, because they're the ones that need it, really. That's my target group, really.

A lot of hospitals aren't even responding to phone calls anymore. Like, literally, teaching institutions do not answer the, the check there. There's not enough receptionists, um, and out and people that are interested in these jobs to where they don't even check the voicemails anymore and return calls.

Yeah.

Crazy.

You got any ideas, Eric?

I was, uh, just thinking about the physicians that I know that are struggling in this manner, and I wanted to make sure that you're good with me inviting them.

I'll be putting it out there. Um, I've got, um, I'll be advertising in Orthopedics This Week. And other, you know, I'm trying to get into, get it into physician practice, but I'm not gonna pay 'em.

Right.

But anyway, we'll see. Great.

Yeah.

I, yeah, that's, that's what I wanted to know.

'Cause yeah.

And I'm not helping with everything I'm asking these guys to do. I'm not helping them.

So I do have a fun plug. Yeah. I, I became officially a, a published author. For research today. Well, I got acknowledgement that they accepted a research paper that myself and two other physicians put together. So never thought an MBA would be in a paper.

Dr. Huffman, I love it.

MBA, definitely not doctor.

Master's.

Yeah.

Very cool.

Take care, everybody.

All right. Bye, y'all.

Thank you.

Happy New Year.

Happy New Year.