Jan 2, 2023Liked by Arpan Parikh, MD MBA FAPA, Amit Parikh, MD
This is a wonderful piece of writing for the new year. It has one deeply regrettable error, which is, of course, not, including myself as one of the visionaries right next to my Nikhil. I also feel like Rik Renard could, and should feel similarly slighted.  I imagine we will both thoroughly shit post the two of you for this oversight. More seriously though, more clinical leader ship in digital health is mandatory. And that means more nurses also I will add.
Favoring growth over clinical rigor is my biggest concern for health startups. Yes there's a lot that could be streamlined in the world of medicine but there's somethings you just can't cut corners around without sacrificing patient safety and there needs to be a strong voice at the table to hold that line when hard decisions are being made. I recently spoke with recruiters at a not to be named mental health start who's main business is dispensing stimulant medications. When I asked them about whether they have a standard practice of having patients check vital signs they could not provide a clear response...which i took to mean the answer is no they don't have any standard practice. This tells me that their leadership either never thought about this or figured that they can tolerate the risk. Neither of those scenarios speaks well to their protection of patient safety.
Thanks for the thoughts Haining! Agreed that the balance of clinical rigor with growth is critical for startups. It's important for more of us (clinicians) to be involved in the decision making process with a seat at the table!
Jan 4, 2023Liked by Arpan Parikh, MD MBA FAPA, Amit Parikh, MD
Thank you for this! 💯 agree with your insightful commentary about ethical responsibilities for managing good patient care from the start, with hopes that quality comes through to both patients, providers and investors. The " "right fit" clinician can be difficult to find but a company also has to have a knowledge base to know what they are looking for when bringing on new team members.
Jan 3, 2023Liked by Arpan Parikh, MD MBA FAPA, Amit Parikh, MD
one obvious misalignment that exists between funds and clinicians is the time horizon of returns. in primary care, we invest in patients across a lifetime, whereas LPs need to cash out in 5-7 years. part of the battle is aligning incentives.
You're spot on Paulius - do you have suggestions for how operators can align those incentives? To borrow from the Mayo, if there's no margin there's no mission, so it's important for builders to figure how to make the business work in those first 3-5 years to enable existing and taking care of patients for decades beyond.
Jan 6, 2023Liked by Arpan Parikh, MD MBA FAPA, Amit Parikh, MD
I think we need a different funding mechanism than VC/PE for health services. which kind of mechanism? that's the next innovation whoever figures it out. step one is detoxing from the current paradigm.
Agree! It will be interesting to see what happens in the digital health startup space over the next 12-24 months with the expected economic landscape. As capital becomes more expensive, startups are going to need to show both profitability X clinical outcomes at an earlier stage rather than blitzscaling (which can, unfortunately, lead to clinical standards slipping).
Jan 2, 2023Liked by Arpan Parikh, MD MBA FAPA, Amit Parikh, MD
Love this post! One question about the early clinical leaders -- you flag two important characteristics to look for, but what should builders avoid when evaluating these potential hires?
Thanks! Far and away, a builder ought to avoid a potential clinical leader who exhibits a lack of intellectual flexibility. Working in a start-up requires the ability to quickly adapt to new external and internal contexts, and debate the pros / cons / alternatives to decisions with peer functional leaders. The clinician is no longer at the 'top' of the decision making food chain, and the inability to complete mental gymnastics would be a non-starter to me.
My one concern, however, is possible confusion around intellectual flexibility measured in the operational/organizational sense as you laid out, and intellectual flexibility in terms of applying the practice of medicine to innovative care models.
In the former case, it's definitely an asset (a requirement, really). But in the latter, it becomes a huge liability, especially for clinical leaders who bow to pressure from other parts of the company, and compromise on standards of care as a result.
100%. To me, the critical flexibility is around adapting traditional clinical models to new modes of delivery and also understanding that not every decision is black and white.
The ideal clinical leader should never compromise on clinical rigor or patient safety. Now, the decision the business makes may not always be aligned with the clinical leader's opinion, but that's ok, and it is a decision the business makes taking into account the informed clinical opinion and judgment of the clinical leader.
This is great — thank you. Question and it might be a dumb one, but who does the CMO or clinical lead usually report to? and do all of the clinicians report directly up to the CMO or is it a COO or operations lead?
I'd be curious to see what a org chart might look like in terms of the clinical side and how it integrates with operations, etc.
Thanks John. On who the CMO reports to, I have a strong bias that it ought to be the CEO. In order to be effective, a CMO needs both the absolute power as well as the relative authority to be peers with the rest of the executive leadership team, and not report into a COO / etc.
On the rest of the clinical team, there’s the ‘on paper’ reporting structure and the ‘functional’ reporting structure. On paper, the patient-facing clinicians may have to report up through the clinical (and not operational) vertical due to CPoM rules (eg need to be employed by the PC, which is owned by the physician lead). What I’ve found helpful is to also have a strong operational dyad structure in these cases, so the clinician manager has help carrying out change management, managing to ops goals, and not dealing with mundane pieces that could be handled more effectively by someone else (time off, vacation, sick time, etc.).
I also have a strong bias that non-CMO clinical leaders should be dyads peers with ops leaders, but report into the CMO. This enables replication of the idea that the clinical voice is just as strong as the ops voice in decision making, not subordinate to / just a check the box role at the regional / state / market level.
Great piece, Drs. Parikh! I definitely agree getting the right clinician leadership is important from the start. The clinical voices in the room will help bridge the gap between present and future. Innovation is obviously a major component of digital health, but clinical leaders will help companies adapt the good things from the past while help setting the vision for the future and make sure that care is delivered responsibly.
This is a wonderful piece of writing for the new year. It has one deeply regrettable error, which is, of course, not, including myself as one of the visionaries right next to my Nikhil. I also feel like Rik Renard could, and should feel similarly slighted.  I imagine we will both thoroughly shit post the two of you for this oversight. More seriously though, more clinical leader ship in digital health is mandatory. And that means more nurses also I will add.
Great piece indeed. My assumption would be that clinicians is an umbrella term for both doctors, nurses, physiotherapist, etc... 😇
That's exactly right Rik :) we used that term intentionally and inclusively
^Yup! And fair enough - we'll take the heat on that!
Appreciate the kind words, and one day :)
Favoring growth over clinical rigor is my biggest concern for health startups. Yes there's a lot that could be streamlined in the world of medicine but there's somethings you just can't cut corners around without sacrificing patient safety and there needs to be a strong voice at the table to hold that line when hard decisions are being made. I recently spoke with recruiters at a not to be named mental health start who's main business is dispensing stimulant medications. When I asked them about whether they have a standard practice of having patients check vital signs they could not provide a clear response...which i took to mean the answer is no they don't have any standard practice. This tells me that their leadership either never thought about this or figured that they can tolerate the risk. Neither of those scenarios speaks well to their protection of patient safety.
Thanks for the thoughts Haining! Agreed that the balance of clinical rigor with growth is critical for startups. It's important for more of us (clinicians) to be involved in the decision making process with a seat at the table!
Thank you for this! 💯 agree with your insightful commentary about ethical responsibilities for managing good patient care from the start, with hopes that quality comes through to both patients, providers and investors. The " "right fit" clinician can be difficult to find but a company also has to have a knowledge base to know what they are looking for when bringing on new team members.
one obvious misalignment that exists between funds and clinicians is the time horizon of returns. in primary care, we invest in patients across a lifetime, whereas LPs need to cash out in 5-7 years. part of the battle is aligning incentives.
You're spot on Paulius - do you have suggestions for how operators can align those incentives? To borrow from the Mayo, if there's no margin there's no mission, so it's important for builders to figure how to make the business work in those first 3-5 years to enable existing and taking care of patients for decades beyond.
I think we need a different funding mechanism than VC/PE for health services. which kind of mechanism? that's the next innovation whoever figures it out. step one is detoxing from the current paradigm.
Agree! It will be interesting to see what happens in the digital health startup space over the next 12-24 months with the expected economic landscape. As capital becomes more expensive, startups are going to need to show both profitability X clinical outcomes at an earlier stage rather than blitzscaling (which can, unfortunately, lead to clinical standards slipping).
markets are much faster to correct course rather than traditional care delivery (eg cerebral vs purdue) so blitzscaling has a quick feedback loop
Love this post! One question about the early clinical leaders -- you flag two important characteristics to look for, but what should builders avoid when evaluating these potential hires?
Thanks! Far and away, a builder ought to avoid a potential clinical leader who exhibits a lack of intellectual flexibility. Working in a start-up requires the ability to quickly adapt to new external and internal contexts, and debate the pros / cons / alternatives to decisions with peer functional leaders. The clinician is no longer at the 'top' of the decision making food chain, and the inability to complete mental gymnastics would be a non-starter to me.
My one concern, however, is possible confusion around intellectual flexibility measured in the operational/organizational sense as you laid out, and intellectual flexibility in terms of applying the practice of medicine to innovative care models.
In the former case, it's definitely an asset (a requirement, really). But in the latter, it becomes a huge liability, especially for clinical leaders who bow to pressure from other parts of the company, and compromise on standards of care as a result.
I hope nonclinicians don't conflate the two.
100%. To me, the critical flexibility is around adapting traditional clinical models to new modes of delivery and also understanding that not every decision is black and white.
The ideal clinical leader should never compromise on clinical rigor or patient safety. Now, the decision the business makes may not always be aligned with the clinical leader's opinion, but that's ok, and it is a decision the business makes taking into account the informed clinical opinion and judgment of the clinical leader.
This is great — thank you. Question and it might be a dumb one, but who does the CMO or clinical lead usually report to? and do all of the clinicians report directly up to the CMO or is it a COO or operations lead?
I'd be curious to see what a org chart might look like in terms of the clinical side and how it integrates with operations, etc.
Thanks John. On who the CMO reports to, I have a strong bias that it ought to be the CEO. In order to be effective, a CMO needs both the absolute power as well as the relative authority to be peers with the rest of the executive leadership team, and not report into a COO / etc.
On the rest of the clinical team, there’s the ‘on paper’ reporting structure and the ‘functional’ reporting structure. On paper, the patient-facing clinicians may have to report up through the clinical (and not operational) vertical due to CPoM rules (eg need to be employed by the PC, which is owned by the physician lead). What I’ve found helpful is to also have a strong operational dyad structure in these cases, so the clinician manager has help carrying out change management, managing to ops goals, and not dealing with mundane pieces that could be handled more effectively by someone else (time off, vacation, sick time, etc.).
I also have a strong bias that non-CMO clinical leaders should be dyads peers with ops leaders, but report into the CMO. This enables replication of the idea that the clinical voice is just as strong as the ops voice in decision making, not subordinate to / just a check the box role at the regional / state / market level.
Great piece, Drs. Parikh! I definitely agree getting the right clinician leadership is important from the start. The clinical voices in the room will help bridge the gap between present and future. Innovation is obviously a major component of digital health, but clinical leaders will help companies adapt the good things from the past while help setting the vision for the future and make sure that care is delivered responsibly.