The AR Show: Justin Barad (Osso VR) on Passion, Conviction, and the Pursuit of Better Medical Training & Assessment (Part 1)

8:13PM Nov 30, 2020

Speakers:

Jason McDowall

Justin Barad

Keywords:

surgeon

technology

people

surgery

problem

patients

called

healthcare

felt

vr

residency

procedures

solve

world

game

medical

early

training

talking

bit

Welcome to the AR show right dive deep into augmented reality with a focus on the technology and uses of smart glasses and the people behind them. I'm your host Jason McDowall. today's conversation is with Dr. Justin broad. Justin is the CEO and founder of Osso VR a fully immersive and scientifically validated surgical training platform. Prior to starting Osso VR, Justin became a board eligible orthopedic surgeon with a bio engineering degree from UC Berkeley, and an MD medical doctorate from UCLA, where he graduated first in his class, he completed his residency at UCLA and his fellowship in pediatric orthopedics at Harvard and Boston Children's Hospital. His experiences as a medical student and practicing surgeon opened his eyes to the many challenges faced by surgeons striving to provide the best care in the face of expanding medical understanding technology and complexity. These insights combined with a conviction to solve the problem led him to co found Osso VR. In this first part of my two part conversation with Justin, we explore his lifelong fascination with ways that software and technology can be applied to help people. He shares his journey of discovery, including some advice he got while still in high school.

You know, you ask a college student, what do you want to do with your life and I told him the whole story. And without any real hesitation, he told me something that is just like burned into my mind to this day, as just, it's very simple, but so true. He said, Well, if you want to invent something, all you need to do is understand the problem you're trying to solve first. And then you'll be able to come up with ideas and how to solve that problem. And he said, and I think that the best way to understand medical problems is to be a doctor, to be on the frontlines taking care of patients, you're seeing it all firsthand. And, you know, he told that to me, and I just, you know, pretty quickly told him, absolutely not like, and I don't think I want to do that much school that much training.

Justin goes on to describe his experiences as a medical resident and practicing surgeon. He also shares the internal struggle he faced been forced to decide between two divergent career paths. As a reminder, you can find the show notes for this and other episodes at our website, the AR show.com. Let's dive in. Justin, when you were young, you had a passion for video games. How did you pursue that passion.

I pursued my passion in video games with great gusto and a lot of hours, I was introduced to video games at a very early age with Apple to see some early IBM PCs video game consoles like Intellivision, Nintendo, Genesis, Super Nintendo, basically, you know, got the opportunity to grow up during the console wars, which was a really great experience. And I just, I really loved stories and video games, I love the challenges. I love the creativity, I loved playing it with friends with family. So I was all about it, I spent a good amount of my time playing games and trying to discover everything I could about it. And you know, one of the games early on that I was really into was a game called life and death, which I don't know if you remember this from the very early days, but was basically a surgical simulation game. It's actually a lot like if you ever played trauma center for the we kind of similar where you're doing surgery, kind of gamified surgery on patients, but you're also diagnosing them and things like that. It's surprisingly advanced for its time, and I loved the game so much, it really made me want to be a doctor. And I thought that was what was so amazing about video games now that I think back on them. And then what we're doing today is that I was inspired, kind of with a career aspiration from a game that I was playing. So you know, I was playing this game life of death. And I was convinced I wanted to be a surgeon. So a cousin of mine is actually a surgeon, I had the opportunity to kind of go to work with him. And I was so horrified by what I saw, I decided I never wanted to be a doctor and that I actually wanted to make video games. And so I made a decision then that I was just, you know, really into computer programming and that that's what I was going to do. And so obviously, that's not where my road led me, but it's just interesting how the journey can go full circle on you.

Yeah, sometimes the pendulum swinging back and forth. So you had an experience, though, I think it was during high school, we had an opportunity to intern at one of the LA based game studios.

Yeah, I was really lucky. You know, I knew some people that worked at Activision and basically got connected with an internship there, which was incredibly exciting. This was really right at the early stages of Activision starting to take off as a major publisher and, you know, they were publishing IP, like, you know, quake and Quake three, Tony Hawk tentu, which is a big favorite of mine. So I had the opportunity to kind of work on these franchises. And you know, what I was actually doing there was I was doing, scripting the the install programs that would basically install the games. On your system, and I was also doing testing and sort of like a second line where the studios would do their own QA. And then we would do an additional round of it and kind of submit bugs and had the opportunity on a quake engine game to actually get a game credit, which is, I think, unusual for a high school student for a game called heretic too. So that was really thrilling. And I think, you know, I was really in a good position to pursue a career in GAMING, thanks to that incredible opportunity. So still, to this day, very grateful that I had that chance to get exposed to what it's really like to make video games, especially at what is arguably the most successful video game publisher currently.

Yeah, that's, that's really amazing. And so you took that experience with you to college with the intention of then studying computer science game programming. When is it that you kind of made this discovery that maybe medicine was important that this notion that the world of health care was something that you want to take another look at?

Well, it really it was sort of a stepwise progression and a gradual shift. And, you know, I had a family member that, you know, had been struggling for a number of years with some autoimmune issues. And it came to a head, my senior year of high school, where there were a lot of hospitalizations, it was really front and center for our family. And I just started to wonder more and more, if there was a way to use software and technology, which I loved so much, not, quote, just for entertainment, but actually to be used to help people. And I didn't know exactly, you know, what, what that was, or how, how that would work. And so I just became more and more interested and kind of fascinated by that concept. And I actually, when I was kind of, we're talking earlier about visiting colleges, when I was looking at UC Berkeley, they kind of provided a list of engineering majors. And there's an engineering major I hadn't heard about previously called biomedical engineering. And literally, the tagline was, you know, using technology like computer science to solve medical problems. And I was like, Oh, my God, this, this is a thing. This is exactly what I was looking for. I think this is what I'm supposed to be doing. So I basically, you know, coming in to count shows that as my major, but with a very specific goal, to invent healthcare technology, I really wanted to create something that could solve healthcare problems.

And how is it is it as a college student, you kind of wrap your brain around this idea of solving the problems of healthcare? How did that kind of lead you down the path that you landed on, which was to then go on to medical school and actually become a surgeon focused on orthopedics?

Yeah, I mean, there were a couple of things that just lined up. I mean, it was really a bit of chance. So as I was, you know, progressing through my, my work account, which I loved Go Bears, by the way, it was an amazing experience. And I loved everything that I was learning, I love my engineering classes. And a lot of the classes were about, you know, learning about these, like breakthrough technologies, whether in orthopedics or interventional cardiology, it was it was so cool. And I was like, more and more convinced that I wanted to create these technologies. And as I was getting close to graduation, I was like, Okay, what do I do after college, and they're like, well, you get a job. And I was looking at these jobs. And if none of the jobs were, like, inventor of healthcare technology, it was like you were, you know, working on some kind of product that already had been invented, and you're trying to get it, you know, to be produced, like 1%, cheaper or faster, and just wasn't exactly what I had in mind. So I was a little bit at a loss of exactly what the next step was on this really deep passion of mine to be an inventor of healthcare technology. So just really, by totally random chance I happen to be out with my mom, and she, you know, brought her gastroenterologist out to breakfast with us, which, you know, he was just very close with the family. And so, you know, he's I, you know, you ask a college student, what do you want to do with your life. And, you know, I told him the whole story. And without any real hesitation, he told me something that is just like, burned into my mind to this day, as just, it's very simple, but so true. He said, Well, if you want to invent something, all you need to do is understand the problem you're trying to solve first. And then you'll be able to come up with ideas and how to solve that problem. And he said, and I think that the best way to understand medical problems is to be a doctor, to be on the frontlines taking care of patients, you're seeing it all firsthand. And, you know, he told that to me, and I just, you know, pretty quickly told him, absolutely not like, I don't think I want to do that much school, that much training. And he's like, take a couple of days and think about it. So, you know, I thought about it. And it just I couldn't argue with that logic. If I really wanted to do this thing where I wanted to invent technology, I needed to understand, you know, the problems I was trying to solve. So, yeah, I went back to him and I said, What do I do? So, I ended up working in his lab, actually, for a year after college. And the unique thing about biomedical engineering is you take all the prereqs for med school just by kind of default, so I was pretty much ready to go. I just needed a little more research. under my belt, which actually in his lab was the study of small intestinal bacterial overgrowth, which sounds really fancy, but at its core, I was basically collecting rat flatulence in Tupperware containers, and then running through them through an analyzer. So if you ever want to know the gas composition of rat farts, I'm your man. And so that research got presented and very proud of it. So hilarious as it is, and then I was able to get into UCLA for medical school and start my real true healthcare journey.

Yeah, wow. Rat farts. I was chatting with my children recently about fossil fuels. And I joke that, you know, fossil fuels oil is basically dinosaur juice. and natural gas has dinosaur farts, which I know is not technically the case. But anyway, talking about animal farts, and capturing it for use, like that came up in conversation recently. That's pretty funny. As you were kind of going through this medical learning experience, whether it was, you know, in the classroom at UCLA or during residency, or even after residency, what, what is it that you found, it was really surprising or frustrating about that learning experience to become a doctor? Well,

there was a lot, you know, I think I had something like, you know, 500 entries and sort of ideas or problems that I was seeing on a daily basis, because healthcare is complicated, right. So, you know, the, the system that we've developed is, is bulky and cumbersome. And there are all sorts of issues, which is, you know, opportunity for innovation. You know, I think, just at a high level, some of the things that I experienced is that, first of all, let's talk about the journey to become a practicing physician, especially a surgeon because it's a bit of a unique pathway. So you spend four years in college, taking your pre med classes, which are like organic chemistry, biochemistry, things like that. And these are things that in practice, you're not using really at all, which is just important to point out, then you're in medical school for four years, two years of that is the preclinical years. So you're, you're in class, this is when you do your anatomy lab, and you're dissections and you're learning sort of the language and various concepts in medicine. And then in the clinical years, you're a part of the medical team, taking care of patients, I mean, really, like you're holding, like bandages and dressings are kind of hanging out in the corner, you're not doing a whole lot, typically, unless you're in a low resource setting where they'll put you to work. And that's kind of where it's more fun for a medical student typically. And then fourth year is kind of, it's more like, do whatever you want with it, and try and get into residency. And so once you're done with medical school, which you pay for, then you apply for residency and you match. And this is where you specialize. So you know, you're applying for internal medicine, psychiatry, orthopedic surgery, plastic surgery, which is now an integrated residency, general surgery, etc, etc. And that can be quite lengthy. So for most surgical specialties, they're at least five years, some of the resonances with research years can be seven years. And then most people like 90 plus percent at this point, go on to subspecialized. So this is fellowships additional year of training. So without a fellowship, all in you're looking at about 14 years, if you include college, and then with fellowship, it can be 15 to 17 years, maybe even more. So it's, it's a very long road. And so, as I made my way through medical school, which I loved, and started out in residency, I realized that medical school has, is not really focused on preparing you for taking care of patients, it's become its own thing, where, you know, it is important to learn the language and figure out what you want to do with your life. But it can probably be streamlined quite a bit. And you're already starting to see this with NYU is now three years and completely free for all medical students, which is amazing. But I do think we could possibly get it down to two years, or maybe even there are some sort of combined programs with bachelor's degrees where you can you can streamline this process a bit more, because it's quite a number of years. So that that was one of my first realizations because I came in on my one of my first weeks as an intern. And, you know, this is probably not a typical experience, but maybe this was just me, you know, I had a patient who, you know, paged me It came into the room, you're very excited as an intern, like being the doctor that someone's calling. And he had just had surgery and he was like, Doctor, I'm, I'm very anxious, and I feel like I'm going to throw up. And I'm in there with the nurse and I look at him, I think for a second. I'm like, oh, that, you know, that's terrible. I'm sorry, you're feeling that way. I look him dead in the eyes. And I say, hope you feel better. And walk out of the room and the nurse cries and she's like, Well, do you want to give him some medication for that? And I was like, there is medication for that. So like nurse, kind of like walk me through everything. And you know, I'm sure most people in medical school are familiar with these medications. Maybe I just like missed that day. But it's I didn't feel like medical school really prepared me for the day to day treatment of patients, it wasn't geared towards that a lot of it is based on the flexner reports, which is this incredible sort of renovation of the American Medical Education System in the early 1900s, which put America at the forefront of global medical care and made it basically an icon to the rest of the world. But it hasn't changed significantly since then. And the problems that we're facing has.

So that was one thing that I noticed, just as an example. And then, you know, in training, over time, I began to realize that it's kind of like, you know, you look at your parents, and you're like, they know everything, right, they can do anything, they know the answer to every question. And you realize that, you know, you're working with these surgeons that are famous world famous is training at these top hospitals. But there's so much that you need to know that even the best surgeons don't know everything. And that a lot of surgery can be quite challenging, it can be something that you've only rarely seen or never seen before. And this was a constant issue. Because there, there's so much, you know, medical care has become so complicated, because we've advanced so quickly in our knowledge of how to take care of things. And so there are certain extreme situations, and this is a story I tell all the time where we'd be using a technology or doing a surgery that we don't do too often. And I would be, you know, at a computer kind of googling what to do, you know, looking up an instruction manual, which is, you know, a perfectly reasonable thing to do, or, you know, even either YouTube videos, or view Medi videos, which is a curated video library. But you know, you're at these world famous hospitals and you know, deep in your heart that this patient who's trusting you with their care has no idea that you guys are kind of like stuck, or you know, things aren't going as well. And you're like double checking that you're doing the right things. And it happened frequently enough that I felt that there was really a major problem here. And it was something that in all of these different problems that I was looking at, and keeping track of and pursuing. This one kept floating to the top to me as something that everywhere I looked in the healthcare continuum, whether it's in the operating room, whether talking to people who are innovators, creating new medical devices, talking with large medical device companies talking with insurance companies, this seemed to be a problem for them. And it just kept coming up again and again. And they became fascinated by it. And wondering if there was some way

to address it. I was recently watching this rewatching, this television series called Chuck, which was on in the, I don't know, maybe 2006 789, kind of that that period was on for five years. And one of the premise of the television show was that the the main character receives basically a download of information into his brain. And he's able to they call it flash, he's able to recognize a situation in which he doesn't know how to solve it. And the information is somewhere logged, that he's able to access. And so in that moment, he's an instant expert. Kind of this, this notion of the vision for what we imagined augmented reality glasses could give us at one point in the future, is that there's enough context that's able to be gathered by the system that's able to recognize what's needed right now. and deliver to you in just that moment, whatever that thing you would have been searching for and studying, you know, asynchronously in order to do this. Anyway, there's kind of this notion of an ideal end state in which you can rely on technology in order to give you just in time, the exactly right bit of information based on the context, the problem that you've got, we're still a long ways from that sort of vision of being able to deliver that on that promise. We're kind of we're in today's sort of technology. How did you kind of recognize, as you have recognized this problem, how did you begin to think about approaching the solution, a good enough solution, kind of deliver make this a better experience for doctors? And for patients? Ultimately?

Yeah, I think, you know, part of it was understanding what the core dynamics were that were taking place and what the data actually showed, because I felt like this was a problem. But was it actually a problem, because how we feel and what reality is often can be quite different. So part of understanding it and reading more about it and talking to my colleagues in the field, really came to understand that there were three core dynamics taking place. The first is that there's too much to learn. So once again, we're victims of our own success, accelerating science and technology has massively expanded the library procedures that healthcare professionals are expected to know on a moment's notice. And it's happening at an accelerating rate. So this is getting worse every day. And I think, you know, probably my favorite story to tell and a very extreme example, and this is kind of like a once in a lifetime kind of thing. I was in residency, I was eating lunch with the team that I was on, which was the oncology team, and we get a page and the attending surgeons working with kind of walks away comes back and you're Very close in residency, so you know when something's wrong, and so it's like, oh, what happened? And he's like, that was the zoo. Gorilla has been pushed off a cliff, they think it needs surgery, and they need us to drive down right away. And I'm like, are we gonna go? And he's like, Oh, hell yeah.

But like, you know, we're driving down there. And we're very confused as to like, why are they calling us and also do gorillas have bones, like we didn't even know what surgery we're gonna do. So we're like, you know, trying to very rapidly read up on gorillas, like while we're driving to the zoo. And, you know, the surgery itself was even more intense than any of us had anticipated, because large animals basically can wake up instantaneously and very violently. So we had like, sort of semi evacuate several times during the procedure, when like, the gorilla, moved his finger, he ended up having a subtrochanteric femur fracture, which we played it and he did great. And it was really an incredible experience. I was like a huge adrenaline rush. We're all like high fiving, you know, people still go down to the zoo to visit him. But I use that to highlight just sometimes I don't think people realize how different any given day is in the life of a doctor, and you just really don't know, what you're going to deal with, you know, is there going to be a train going to derail and you're going to get some sort of like, mass casualty event, or are you going to get called by the zoo to operate on a gorilla, like, it's really, it's part of the excitement, but it's also it's stressful, because you don't know if it's going to be something that you know exactly what to do. The second part of the problem is the increasing complexity of the procedures themselves. So counter intuitively, advances in technology while they have made surgery safer, more repeatable, it is more complicated than traditional surgery. So doing a surgery, minimally invasively, or with robotics, or navigation, or patient specific guides, or implants, is actually harder to learn. And so the learning curve for these more modern procedures is longer, sometimes 10 times longer. So it may take 100 cases, before you can master one of these newer surgeries. Yet, the way that we were learning to use them was exactly the same for these much simpler approaches. That was another thing that I was noticing. And then the third part of the problem, and it's something that I talk about a lot, because I don't think people really know this is that there is almost no technical assessment that takes place for healthcare professionals, especially surgeons. So to give you an example, what I mean, I still practice on weekends as a pediatric orthopedist. And the only time in my entire career that I was objectively assessed. So there was some sort of repeatable evaluation that was performed, it's not just someone saying, like, he's pretty good, you know, I was interviewing at a program and they pull out the board game operation. And they had me you know, try and remove a plastic piece without buzzing, which I did, and I'm very proud of, but it just highlights that we don't have a system to ensure the consistency of what a specific type of healthcare professional should be able to do safely. And, you know, I saw an example of kind of the results of this myself as one of the hospitals that I trained at, we had a patient come in with a life threatening injury. And you know, you only had a few seconds to do you know, this pelvic external fixation, which is a life saving procedure, it was the general surgery team to go in and fix whatever major bleeder or internal damage there is. And the team that I was working with the supervising surgeon felt uncomfortable doing it, because he hadn't done in like a decade. But one of my trainees that had done a bunch recently, just randomly, so she ended up kind of doing this the case, basically, and the patient was fine. But to me, that was like, a really crazy thing, because in the aviation industry, you train for these type of events, which are often called low frequency, high urgency situations, every six months, you'll train in a simulator to make sure that, okay, if these things happen, that, you know, everyone on board can die. So here's how you get out of it. And you need to continually demonstrate that you are capable of getting out of those situations by running down specific checklists. But we don't have that right now in healthcare. And so we're just relying on people to hopefully kind of know how to do it or someone around knowing how to do it. And so, if you haven't yet heard the podcast, Dr. Death, I think it's a really obviously, unusual tale like that. That's most surgeons, most health health care professionals are incredible professionals and they're great, but without a system to really objectively understand the safety of our practitioners. You can't every now and then run into a situation like this, which is very extreme. But everybody knows someone that's on this kind of spectrum that is, for whatever reason, just not safe operating, but There's no real system to identify those people and, and to intervene and to help, you know, not not punish them. And so I definitely highly recommend that people listen to the podcast because I think it's, I mean, very entertaining, but also highlight some of these issues that we have currently.

Hmm. So you've got these, these intersecting trends are challenges, right that the industry is dealing with, amount of things you need to know goes up, the amount you need to know about each individual thing goes up. And there's no system for assessing, and ultimately maintaining or improving the ability of the surgeon to do the set of activities that they might encounter, especially the sorts of less common ones. And so you took this kind of triumvirate of, of observations? And how did you kind of put them together in developing or thinking through a solution.

So I'm seeing all of this firsthand. And I'm like, okay, here's the problem. I'm understanding it more every day. And in parallel, I still love video games. So I'm playing games, I'm involved in the world of gaming, and I hear about the Oculus Rift, DK, one Kickstarter, and I find it very exciting. Um, I don't think there's been anything that I've, like read every single forum post, like if there was a new post in like about anything with VR, like I would know about it, I was just really excited. And then finally was able to get the headset and not only the headset, but, you know, through the forums was able to figure out how to hack together the six cents motion controller, so you could get your hands involved, too, which is hard to do in the early days of VR didn't didn't kind of come with it. And so I don't know, if you did, you were able to use the DK one,

I've never actually experienced a DK one. By itself, I think a DK two was the first that I had experienced,

okay. So you know, the DK one came with the this Tuscany demo, it was called where you're like in a villa in Tuscany. And I was able to use a version of that with the controller. So there's some chairs and books that you can kind of pick up and kind of walk around. And after that experience, it took the headset off, and I'm like, I can train surgeons with this, like 100%. And it was interesting, I was like, this is going to solve this problem. And my first sort of reaction was, I can't wait till someone uses this technology to address this issue, you know, and it took me a little bit of time to realize, like, I don't know, when I woke up one day, I was like, Wait a second, I can do this, I can program I'm like, this is what I've been looking for. And so it was interesting that there was a bit of a disconnect. And I think this is an issue that, that people that are interested in innovation have is especially if you're in something that's very academic, like engineering, or medicine, where your progression is based on other people's sort of permission for you to do something, right, you need some sort of diploma or degree to advance to the next level. And so, you know, in my mind, I think, at varying points, I was waiting for someone to be like, okay, you can create a technology or a company now, you've like, cleared this milestone. And that's not how this world works, it's more of a realization that you just have to do it and create something from nothing. And a lot of people are probably gonna, and this is where a lot of that very early in our conversation, we're saying there's like a fine line between because a lot of especially early stage ideas like are not, don't seem like great ideas for people, that's probably why it doesn't exist, you know. And so, there was a fair amount of kind of pushback when I was kind of floating this around to people because people thought it would never work or never be high enough fidelity, and you can solve the problems, etc, etc, which we can talk about later. But there's, there's quite a bit of resistance to even just like sort of getting this off the ground. But I have all of the ideas I ever had. Like, like I said, I could not stop thinking about this. I like I felt compelled to work on it to address it. Because I was it came from a place of passion for sure. But also of concern that I loved medical technology more than anything, like my whole life was built around it. And I love medicine, I love taking care of patients. And I genuinely felt that the direction things were heading that it just this system was not going to hold up. And someone really needed to do something about it. So that was kind of like I had this sort of like driving urgency as well that someone needed to jump on this. And I didn't feel like anybody else was

at that point was the idea of formulating it kind of as it related to making this thing real bringing it to life. was the idea that you would be the one that would carry it forward? Or is this something in your mind that you would just kind of help somebody else get it going? You kind of pass it off pass that torch?

Wow, that is an incredible question. I don't think anybody's asked me that before. I definitely I mean, to be honest with you, it was the former. I thought I would create a prototype, you know, get this up and running and then like a team would just sort of take it and bring it into the world and solve this problem magically and I would kind of Keep going as a surgeon and spin out other ideas or things like that. And I grew to realize that's not how these things work. You as sort of the initial spark for an idea, you have to be there, you're, you're the fuel for the fire, you have to somehow convince people to jump on what is, you know, 99.9% of these things are going to fail, right? Like, you need to get people on board, you need to get people excited investors, customers, recruiters, employees, users. And it's the reason why startups do as well as they do is that it's people want to be excited about something, they want to see the future. And it's not going to be some crack professional technology team that's really going to, they may deliver an awesome technology, but everyone needs the vision, the guiding light, the passion and the excitement. And also, like I said, not only 99% of startups like gonna fail, but 99% of the things you do in a startup is not going to work. And so you need someone who basically is going to keep going, no matter what happens, because anybody else under normal circumstances after like the first 100 kind of obstacles, you're like, you know what, I can get into something that is a bit easier and more secure. But if you are someone that is just like this needs to exist in the world, we need to solve this problem, no matter what obstacles pop up in our way, I don't see any other way of bringing forward without that and realizing that that you are that person. And that's inside of you is a critical element was sort of another step on this journey that I you know, I realized, and what's interesting is a lot of other health care professionals, which is it's becoming more and more of a thing where, you know, physicians and training, nurses are reaching out to me, and they're like, hey, like, I have a technology or an idea. And I'm, I don't know how to balance it like, do I pass it off to someone just like this? Do I drop out of work completely? How do I juggle all this? So this is more and more, I'm realizing an issue across the industry. And, you know, I tell people that if if this is you're not going to be able to pass this off, it's not going to nothing's going to happen with it. I mean, anything is possible, maybe, but it's you are that central element. And you know, you need to find a way to stick with it in a meaningful way to drive it forward. If, if that's what you want to do.

Yeah. I think for a lot of product oriented founders, the advice that you got would would resonate with that advice around, you have to really understand the problem. So often, I think as entrepreneurs approach this idea of company formation, an idea comes, right, they might observe something they haven't don't live the problem that they are attempting to solve. And so having a truly intimate understanding of the problem, and maintaining that understanding as you're developing a solution, right, to truly fit that solution to exactly meet the needs of that problem, is one of the biggest challenges. And one of the biggest failings of most startups is this disconnect between the problem understanding and the solutions fit for that problem. And a problem understanding goes beyond simply the the nuances of you know, what is the thing I'm trying to solve, but also includes how does that thing exist in the overall ecosystem, or workflow, things that exist around it, right? When you think about a training solution, a simulation based training solution, as you have developed, it doesn't exist in isolation, as the only installed training or assessment tool that exists within that health practitioners life, right, you have to have this kind of deepen into understanding anyway, this is a long way of kind of getting at this notion that having experienced the problem is such a great ice from which to though, then go and develop a solution. And I agree with you that it's so often when an idea is generated on over here and is passed off. That is when it dies. That is when a dies is the moment that thing is passed off. So you recognize this very early in your own journey that you cannot hand it off. How did you come to terms with this notion that you really did need to dedicate so much of yourself so much more of yourself to making this thing real, relative to what you were doing day to day previously? Which was being a full time surgeon?

Yeah, well, that was, you know, a very challenging crossroads, and kind of a big fork in the road of my life. I was, I just finished my fellowship at Harvard. And, you know, when when I was kind of finishing residency, I had a very similar sense about when I was finishing college of like, how do I, how do I be innovative? How do I be an inventor, because I was, you know, heading on a track to be a full time surgeon and I still didn't exactly know what to do. And I heard about this program at Stanford called biodesign, which is a medical innovation fellowship that espouses need based innovation, which is sort of how I've been living my whole life. I'm like, Oh, this is perfect. And you know, they put you in a group of engineers and doctors and you identify problems and solve them together. And I thought I was like, Okay, this is just like how I discover about engineering. This is the next step for me to kind of pursue this career. But this Osso thing was sort of starting to grow. And by the time I got into Stanford, I also was starting to get a lot of interest from investors and customers and, and I was getting more excited and interested in it. And so there was actually a moment where the Stanford kind of team sent me down, and they were like, hey, you're here, but it seems like you want to do something else. And, you know, you may see a lot more success if you kind of pick one or the other. So I kind of, I kind of had to choose one I was I was, I was only half in on two sides. And, and because I couldn't commit 100%, I wasn't really being as successful as I wanted to be in any aspect of my life. And so it was a really stressful moment for me, because this is a program that was very competitive is very hard to get into. And it was kind of my dream, but I was choosing between another dream as well. And there's also the sense that if I were to leave Stanford that, that would burn a bridge that, you know, would be too long to go back to, you know, where I was really heading into academics, and you're looking at positions at UCLA, UCSF places like that, and they may not want to take someone who dropped out of, you know, a great program at Stanford and spent time on a startup and kind of like doing part time surgical work. So, you know, I was I was driving home, and I was just like, so in my head, I actually ended up hitting an ambulance,

which is, the irony of that is very high.

Everybody was fine. But I mean, just a highlight, like how distressed I was about this, this is really hard. And I think, you know, I'm talking, I was talking earlier about other residents and healthcare professionals that reached out to me this is, this is a really difficult decision, because you've given your whole life to something and, you know, you could be giving it up to some extent to pursue some some passion that is very high risk, you know, and, and so it's, it's, it's hard to reconcile that for a lot of people out there. And that's something I want to continue to help people with however I can. So I thought about it. And I thought back on a moment that I had, where I was interviewing for a fellowship spot in Canada, actually in Toronto. And it was really interesting, the the director there, he looked at my application, and he closed it, and he was like, okay, clearly, you're a different kind of applicant. So I'm not even gonna interview you, I just want to give you some advice. It's like, Okay, this is interesting. And he was like, don't worry about trying to do things that you think people, you know, what success classically is, you know, don't don't try and fit into a box, just do what you're passionate about. And successful find you was sort of the gist of what he was saying. And in this moment, you know, as I'm signing the insurance paperwork for this ambulance, I thought back on that, and I'm like, this is that moment, this is the moment where I have to choose between what is the classic definition of success for my life? And what am I truly passionate about? And what I was passionate about was solving this problem in healthcare to the point that I've said, Okay, 99.9%, this is not going to work. What what would happen if that were the case, one year from now, three years from now? Well, if I move the needle, even a little bit, like, I solved the part of the problem, or I got people talking about the problem, I would feel like I did a good job, even if it didn't work. And so I went back into the office at Stanford and, and I said, I'm sorry, I'm, I'm pursuing my passion. And the next day, I showed up by myself at a coffee shop, because I was working remotely with my co founder. Who would I'd only met in person once. And I was like, here we go. And that's how it all started.

Wow. Wow. You really cut the the umbilical cord on that one, right. Took off the training wheels.

Oh, yeah. Just going down right out of the deep end. Yeah.

Wow, amazing. And as you sat there, across the country, working with your co founder on creating what has become Osso VR, what is it in your mind? How did you articulate to yourself to your co founder to the other early members of the team, what it was you were ultimately trying to accomplish?

Well, I think we both brought different hopes for the company to the table. I think for Matt, having worked in, you know, professional gaming for a decade, like Electronic Arts. He never wanted to step into an office again. And he thought that working in an office in person didn't make sense anymore with technology, especially with virtual reality, and that we should be a company that eats our own dog food, and that uses VR to maintain that sort of team culture and atmosphere. So to him the most important thing was to be a fully remote company, which we are and kind of like to say that we did remote before it was cool. For me, when I was doing my residency in orthopedics, I had a couple of experiences that led me to go into pediatrics. You know, one was, if you've ever seen the movie Gatica, there's a moment where it's, it's where this guy is trying to impersonate Someone else basically and he needs to get taller. So they do the surgery to like lengthen his legs, which I thought was, you know, like Star Wars Star Trek science fiction type thing. The first surgery I ever did as a resident was that surgery, wow. And I was like, Oh, my God, this is like magic. So that was, you know, a pediatric procedure. And then I had another experience where we had a patient who grew up with a clubfoot deformity, which you can fix when you're still a baby, but it hadn't been done. So you've been walking basically, on his tibia his entire life and been quite deformed, it's very painful. And so as like a 15 year old, we did a salvage surgery, it's not ideal, but you basically remove a bunch of bones, you fuse them together to get his foot back under his ankle. And when I was walking in to the clinic, I could see him at the corner of my eye, and he grabbed his dad, and he said, Dad, dad, dad, that's the guy that made it so I could walk again. And like, I like, teared up, I tear up just telling the story now, and I'm like, I need to do I need to do pediatric orthopedics like this is this is for me. And I think what attracted to me to pediatrics, like part of why those stories really resonate with me is the mission driven nature of helping children. Medicine is complicated, you know, taking care of people there, there are a lot of competing priorities, egos, there's money, there's time, there's there, all these things going into it. And then there's the patient, and you know, they're in there somewhere. And obviously, they're very important. But when it comes to helping kids, that is the most important thing. That is what everybody wakes up and comes to work to do. Everything else is secondary. And I found that that's how I wanted to work. That's how I wanted to live as part of a mission. And so I wanted to bring that same concept to Osso. So what we came up with together, Matt nine, that really team was that our mission is to improve patient outcomes with better education and assessment, we can make surgery better, not necessarily by what we're putting in people, but how we're doing it. Secondly, is we want to increase the adoption of higher value medical technologies, these newer technologies that are available for patients make surgery safer, and more repeatable so that your family, my family, doesn't have to worry as much, they don't have to Google their surgeon, they don't have to call their aunt or their uncle and ask how their experience was. But what is limiting the adoption of these technologies is a lack of training. And then finally, democratizing access to surgical education all around the world, I've had the incredible privilege to go on medical missions. And my friends have also done this in various countries all around the world. And you have viewed the most amazing, technically gifted surgical teams all around, that don't have access to the same educational resources that we do here. But they can with a $300 headset. So that is also a very important part of our mission as well, no matter where you are, where you grew up, whether you're a patient healthcare professional, you deserve to have access to the same quality of care, at least when it comes to the technical competence of the team.

Yeah. Powerful as you make that real, that's going to have a profound effect across a huge number of people on this planet. And as you're kind of articulating this mongst yourselves. And you are kind of developing what the initial embodiment of this vision is, in terms of the product, what were some of the kind of biggest challenges, they're really in the early days of getting that company and the product off the ground?

A lot.

You know, in the early days, that the technology, you know, has all sorts of challenges around it, you know, it's not perfect, it's got a lot of bumps and blemishes and friction. And so what became clear to me very early on was that we needed to identify a value proposition that was so strong that it was existential, that we needed to find a customer that needed to solve a problem so badly, they didn't care if the technology wasn't perfect, or wasn't all the way there yet, which was some of the feedback that I've been getting, right. It's like some people weren't interested in VR, because it didn't 100% solve the problem, which I don't think you need to, but we need to define someone who it's like, hey, if this solves 60% of my problem, like this is gonna save our company. And so to me, that was the medical device industry where I was, you know, in the process of being shown how to use a new spine implant system, hip replacement system navigation system. And these companies spend a lot of money flying you to a hotel or a course where you have the opportunity to practice with the device. And you'll practice maybe one or two times, and then do the actual surgery, sometimes months later. Now, we talked earlier in the interview about the learning curve for modern medical technologies, which is 50 to 100 cases. So you're in the operating room, you're using a device that you use one to two times that you have to use like 50 to 100 times to use well, three or four months ago, that's not going to go well. And so these are procedures that have been in work You know, I'm at the computer and the ref were yelling out instructions, it feels very unsafe, nobody likes it. And the consensus is always this devices. It's not for us, it's not safe. It's not good for patients, when in reality, everyone was just under trained. And there was no checkpoint to make sure everyone was ready to use it. And so I felt that, you know, the second part of our mission, that medical technology was not being adopted due to a lack of training and assessment options that were more flexible and repeatable. And so we felt that in the medical device industry, that we would really be able to get some early traction, which, you know, within a couple of months, we're up and running. And that really worked out really well, for us, we now work with in 12, medical device companies are being used in 20 countries. So that early hypothesis was crucial for us, and really, almost laser focus, you know, deciding it's like, here is the key value proposition. That's all we're gonna sell to right now. And I think that was really important, too, for some of that really success and traction and really acceleration. And a lot of that, you know, I didn't, I didn't come up with this philosophy myself, but you know, I've been reading about, you know, why was PayPal so successful, it's like, they really targeted one key user demographic, high volume sellers, and they're like, you know, we're just gonna create a product for this group, not trying to make everybody happy, because we can get really growth very quickly from them. And then, you know, you start to get network effects, and it spreads to others. We look at Friendster versus Facebook, where friends, there's like, we're gonna work with everybody all at once. And, you know, they imploded in some ways. And then you look at Facebook, where they're like, we're only going to work with certain colleges. And we're going to let more in over time, and we're going to be very sort of intentional about who we work with, and what we work on and maintain that focus. So I think that was an early decision that really paid off for us. I think, in the early days, you have to make everything happen. Nobody's nobody knows who you are, nobody's reaching out to you. nobody's asking for anything. So there's a lot of sort of creating something from nothing like you have to just, you have to insert yourself into the conversation. It's, it's, it's really interesting, and there is a lot of spaghetti against the wall, you're like, hey, like, you know, let's, let's do this, and let's promote this, let's be at this conference, let's talk to these people. Like, let's reach out to them, like, let's get in there. So it's really fascinating, because, you know, I can see the dynamic changing now, where, you know, if you read the hard things about hard things, there's, you go from when you're in the really, really early stage content generating where you're just having to make things happen, because nothing's gonna happen without your input to now your interrupt kind of driven, where, now a lots coming in, everybody wants something, everybody wants to work with you. And you need to be like, Okay, what segment of all of this data coming in, am I going to respond to so it really it shifts quite a bit in between those two stages.

It's a great insight early on, that the medical devices are the ones that felt the pain severely enough, they're willing to put up with the blemishes, as you noted, and kind of adopt this technology, because it helped them serve their mission so much more effectively, right? Because ultimately, for them, it's about how do we sell and, and make successful the use of these advanced technologies that we've created. And using a technology like VR simulation really moves them much further down that path. And so it seemed like a really excellent fit this this initial focus, as you are now a bit more mature as a company? How do you think about moving beyond medical devices, companies as kind of your your anchor customers. Beyond that, what's the thought process there?

This is a problem that affects every healthcare professional that performs technical skills with patients, of which there are roughly 30 million around the world. And the ultimate vision were for us to consider our mission achieved is for every single healthcare professional using VR to train and assess themselves. Now, we're not going to be able to do that overnight. And you need to have a stepwise progression in which you tackle specific markets, you create a repeatable technology that has product market fit, and also a go to market that is like a machine that just kind of can scale as you put more inputs into it. And once that's going, you can start splintering off into additional markets. So once you feel like you have that kind of perpetual motion machine going, that's when you can start to look at additional markets and various ways to utilize this technology of which, you know, I don't necessarily go very deep into our strategy, but there is really no stakeholder and healthcare that isn't going to benefit greatly from from what is almost completely absent currently, which is our knowledge of our technical risk profile. So, you know, this healthcare professional, this nurse this mid level, this doctor, what procedures can they do, how well can they do it? What is their aptitude for doing other procedures more complex procedures, less complex procedures. Let's put them in an area where they are going to be most efficient in terms of their cost and the value that they're generating for the healthcare system. And when we're interviewing people for, for residency to work at a hospital, let's make sure on the front end that we're bringing people on that can do the job. Because right now, that doesn't happen, you know, when when I got hired, there was no technical evaluation, that was part of it, you know, it's like, hey, he, he wrote good notes during his training, you know, it's like, he's a nice guy. But I may be a terrible Sir, I don't think I am. But I, you know, I could be terrible, and it's a, it's a risk that you take is roll the dice every time you're hiring, and the thousands and thousands of people that healthcare institutions need to hire. So this is a huge problem for everybody from healthcare institutions, payers, malpractice insurance providers, the medical device industry and, and patients at the end of the day, who, once again, like, when you get this, this is like the craziest thing to me, when you get on a plane, you don't know your pilots name, you're not googling their Yelp reviews, you're not calling family members to see how their experience was with this pilot, because you know, you're going to have almost the exact same result every single time. But when we go to get a procedure, or to go see a physician, we do do these things. Because we know deep down that there is a lot of variability in the outcome depending on who you're seeing. And that's where we really want to level the playing field where in combination with it's also not the whole solution. Don't get me wrong. But this is an important step towards making sure that healthcare outcomes, especially when it comes to procedures are like flying a plane is almost the same every single time. Part of it is robotics. Part of it is going to be training and assessment to ensure that technical skills are consistent across the board. And other AR technologies that you guys are looking at in the operating room as well. And some non AR technologies like a veil, or remote proctoring. And mentoring platforms are really exciting. But you know, you're seeing just a massive seismic shift it because of the world that we're living now, which is this kind of COVID and this future post COVID world where a lot of this digital transformation has been accelerated, because we don't have a choice. But these were things that we definitely had to do for some time.

As somebody who takes evidence very seriously, as a student of medicine, how, how do you know that these VR based simulation training sorts of solutions actually work that they actually move the needle in the right direction meaningfully? I continue my conversation with Justin in the next episode, we talked about the imperative to improve medical education, and how using VR based tools can have a broad and deep impact. He talks about his concept of the trust curve, his take on VR versus AR and startup leadership principles he's learned along the way more great stories and insights ahead. Please subscribe to the podcast you don't miss this or other great episodes. Until next time.