HackED! How to scale your hardware/software solution

- Super excited to have Joe Habboushe here. You're rolling along with our speaker series guys, so we're towards the end now, which is really exciting. And as you know, we've had the software and hardware tracks. So today's a more software focused talk on scaling. And so I have Joe Habboushe here. He and I go way back. We were just mentioning for those who just jumped on that we met nine years ago, he has been a really important mentor for me in my EM career and innovation career. He's the co-founder and CEO of MD Calc. And so he is gonna be talking a lot about his experiences with MD Calc. He's also done a bunch of things in the pharma space, a serial inventor in that space as well. And he is a practicing emergency medicine physician. In New York he's been in a bunch of the different academic hospital systems, works at Cornell now, and he went to residency in New York as well. So a New Yorker through and through in terms of where he is at now. But yeah. Welcome, welcome Joe, and it's great to see you.

- Oh, thanks so much for having me. This is so fun, so cool that this is happening. I don't think we had this back when I was coming through medicine. I'm just gonna try to set up, see where you guys are here. All right. All right guys. So, I just mentioned this. I wasn't, I just had a title to go with, so I took a step back and thought what would I would've wanted to hear about when I started this process, which is, MD Calc's almost two decades old, which blows my mind. It's a long slog working through these things and scaling something. And so I thought I'd just give a really personal story about what my path looked and we can talk through that. So this is my scaling MD Calc talk, AKA two nerds trying to make medicine and math cool and popular. So conflicts, which is also just innovative stuff I worked on, which Karan mentioned, I'm co-founder and CEO of MD Calc. Something else I'm working on is in the pharma space. I'm working on a neat project now with a few different other folks who are working on it, on developing an oral ketamine for pain. So we have patents on it working with Sergei Malta, which who's done a lot of the clinical studies in emergency medicine for pain and a bunch of other folks. And we did our preclinical trials, all the animal studies, and we're hoping to launch our phase 2A studies at hospital for special surgery and post-op pain. Really cool and meaningful if this works to have a non-opiate pain medication. And we all know how interesting ketamine can work. So, and another entrepreneurial thing I worked on, which was not a business, was a guidebook. When I was coming through residency, I had such a problem trying to remember the differential diagnoses, et cetera. And so came up with this idea of just making a really, really simple guidebook. It is a similar idea as MD Calc, I think, an approachable way to approach clinic differential diagnosis and chief complaints. And got lucky and met the guys at EMRA when I was working as a resident on this project. And now we're working on our fifth edition, I don't know, 15 years later. So I think there's a lot of really interesting entrepreneurial things you can work on that aren't always businesses. All right, so we'll do some questions for the audience here just to keep it fun. So trivial pursuit. Now there's two questions here. I want everyone to answer both questions. And the, so there's two symbols here and the questions are, which is the caduceus and which is the correct symbol of medicine? They might be the same one. Okay, so for caduceus, you've seen me do this one before I think. So the caduceus, who thinks it's the one on the left with the wings, and who thinks it's the one on the right with the staff and the one the snake. Okay, so more people think it's on the right. And then how about the correct symbol of medicine is the one on the left anyone or the one on the right? All right, well the caduceus is actually on the left. It's the wings and the two snakes, but which is not the correct symbol of medicine. That's the actually the wine of Hermes, right? The staff of Asclepius is the correct symbol of medicine. We say the wrong words. Asclepius was the god of medicine, right? So Asclepius was the god of med, and by the way, the only organizations that get this right most of the time are the EMTs. Just look at ambulances, they always get this right. Most medical systems get it wrong, most companies get it wrong. So if, Asclepius is the god of medicine, who is Hermes? So Hermes is the god of business and thieves and war. So this is how I to start some of my business related medical discussions. So again, as I wanna tell a little bit of a story of my background and how I came through and got into medicine and what I learned about myself along the way, because I think it was really helping me understand, really helped me get to where I am and help scale MD Calc through that. So it starts with, look, I'm a kid of immigrant physicians. It's a pretty familiar story, but through that I was actually stepped away from medicine because of it, which I think I was so surrounded by medicine and so intimidated by my family's story that I couldn't, I didn't really feel I could measure up to this family that I was part of. So these are my parents. They were physicians, they're both physicians from Iraq and they had to escape the country to come here. My mother was a female physician in Iraq in the sixties. They both, they live in Philly now, my mother still practices in her mid eighties. My mother's dad was a neurosurgeon. He left Iraq to train in Edinburgh and invented medical devices in the mid-century. His father was this famous doctor in northern Iraq called Dr. Baba who him, he was a fourth generation doctor, which means my mother is a sixth generation doctor. Totally intimidated. Dr. Baba did these surgeries, the original plastic surgeries on noses, you guys know about this 16th century nose jobs. And so in that region at that time there's in the country sometimes women were punished by getting their noses cut and they would seek out Dr. Baba who would do this. And not only that, but we're from this group called Assyrians. And now he lived during this time of the Assyrian genocide, somewhere between 50 and 80% of Assyrians were killed. If you don't know who Assyrians are, that's because the genocide was so terribly successful. And so he actually led a group of people out of that and started an Assyrian national party when Iraq was being, I felt I could not live up to this family. And while I loved medicine, I was actually a math nerd growing. I was the captain of the math team in high school and ended up going to college as a pre-med and then quickly didn't see myself the medical doctors around me. I really, I felt I love medicine and math and I dove into math. So I dropped the whole pre-med thing and I became a math major and I'm really glad I did. I really, really loved math. I didn't know what I was gonna do with it. It didn't seem practical at all, but I figured I'd figure it out along the way. And I graduated college and I didn't know what to do with it for sure. So I traveled for a while and then I started noticing another part of me, which is I really to build things and this felt very different than medicine in the medical path, which felt very laid out for you. So I was attracted to that and intimidated by it. I started discovering I could just build things on my own. So I did some entrepreneurial things in 1999, if you guys remember what that year meant. And I'm dating myself here, but that was in the first .com boom. I started a web-based email company of all things. So this was a year after Hotmail was created. It was web-based email was new and I was a kid just trying to figure out how to do stuff. And in a year I made more money than most of my friends. And the following year I had spent it all. I learned a quick lesson about how you can learn to spend money very, very quickly. And I think you guys probably know the story of the .com boom. I had entered it probably right here and had no idea what I was doing. So I didn't make, I just started going up on it and then crashed and learned a ton, didn't know what was next. And so I escaped to Argentina and lived in Argentina for a while post-college. And while I was there I reflected on all these things that I had been learning about myself. I wanted to be entrepreneurial or at least build something new and that felt not aligned with medicine, but I was really getting attracted to medicine and realized I'd ran away from it for the wrong reasons. And so I ended up going to med school with the idea of doing an MDMBA. I figured this is a good way to try to marry these two things, not a lot of people who do both at that time and let me figure it out along the way. So I ended up going to Cornell Med School in the city, which I've been close to ever since. And I was elected to be the student on the board of trustees essentially. And back then I was already talking about I wanna combine these things. I didn't know how I was gonna combine them, but I figured I'd try to combine them. So that was, I don't know, 20 years ago now. And then I ended up doing business school at Columbia Business School along with med school right here in New York City. And at the time, and this was a really, really great lesson for me, at the time there was, in business school, the hot thing, the thing that everyone wanted to do was work in private equity. So this was another really important financial time, if you guys remember historically in '07. So everyone was interested in private equity and venture capital. Entrepreneurship wasn't very exciting or hot then. And so I wanted to do private equity or at least I thought I did. And I think there's this phenomenon where especially doctors who are driven and are competitive, we always wanna do the hardest thing and we feel that makes us whole, or that's how I felt for sure. And in retrospect, I'm really glad I sort of thought through this better. I got a internship at a top private equity fund, ended up getting an offer to join a venture capital fund straight out of business school, which would've meant I didn't do residency. And came really close to accepting, I was dating someone at the time and she was going from business back into medicine and she just sat me down. She's like, what do you, do you really wanna do this? And it made me reflect on why I was really making this decision. I think I had the insight enough to know I still wanted to practice medicine and that this private equity thing was just what was exciting at the moment. It was a shiny moment. So I ended up doing residency and a year later we all know what happened in '08. So I looked a genius afterwards, but I had no idea what was going on there. I dodged a bullet and in a residency I met this other resident, Graham Walker, also fellow nerd as you can probably tell here. And he had already started this website MD Calc's the original MD Calc logo. And immediately I realized we're gonna become friends 'cause this is all of my interests all in one in a way I could never imagine it. It was medicine, it was math and it's this talent I might be starting to develop to bridge these two worlds and it's a chance to grow something. And I don't think I could have taken any other path and withstand how much work it's been to scale MD Calc. It's such a slog if I didn't really love what I did. And so I think my first takeaway from this is do what you love, really try to figure that out because it's so much work to get there. So that's my first step there. All right, another trivial pursuit. We'll see if anyone knows these answers. This one, someone has to try to answer. So to which god do we pledge the Hippocratic oath? For those who are doctors, we all gave the Hippocratic oath. And who is that god's son. Do you remember Karan? You've seen me?

- [Karan] No, I've heard this before in one of your other talks, I still don't remember.

- [Joe] So the god is Apollo and his son is actually Asclepius which is the god of medicine, the staff from earlier. Cool. So the next section of the talk is just talk about the healthcare economy 'cause I think what I find important is when you enter into the business and healthcare is the healthcare economy is so vast and has so many different parts, understanding where you fit within it is really important. And if you're undifferentiated yet, figuring out what, how you wanna fit within it, I think is really important too. So first of all, the US GDP is $27 trillion. So do you think that what we spend on defense or what we spend on healthcare is bigger? And a lot of people think about defense being very, very big, but it turns out defense is big. We spend about 3% on that on defense but we spend a whole lot more on healthcare almost $5 trillion now, it's about 17%. That's larger than the entire GDP of the continent of Africa just on what the US spends on healthcare. We're 4% of the world's population. As a full economy it would be the third biggest economy in the world our healthcare industry. And now look at the sectors within this gigantic industry. And these aren't apple to apples comparisons. These are just big picture slides here. This is profits across sectors. But what I wanna point out is the health IT is actually a smaller segment of this. Most of it is still pharma, providers, medical systems, bricks and mortar, payers, even med tech's a lot bigger. So health IT is really hot right now. People talk about it a lot. It's not the main segment of healthcare expenditure for sure. And then within health, digital health, this is also really interesting. I think a lot of people don't have this perspective. The telehealth makes up the majority of digital health. Have you guys seen this before? And what's even interesting is telehealth, and this is peeking into the future. So we'll see, maybe it's not gonna be as big, it actually comes in different forms. So there's the telehealth, which is, we in the ER we use telehealth to see patients. I see my own primary doctor through telehealth sometimes. But there's a lot of companies that we call this is the investments in the past few years, a lot of 'em went into this on-demand healthcare, which is often companies that are found a loophole to avoid having to see a doctor to get a prescription. When I go into the New York City subway, there's ads on how I can buy GLP1s without really talking to a doctor. I just probably click something in an app and a nurse practitioner clicks that and writes me a prescription, So this isn't real true innovation, I would argue this is finding a way, this society's decided that there's gatekeepers to certain medicines and there's companies that found a loophole around eight . It's not really I mean this is, it might me just making this argument that's not true innovation there. So we have to be really thoughtful when we look at these different spaces about where you wanna fit in and how innovatively you wanna change medicine. And I point this out so here's a actually specifically in a space that I'm working on, ketamine, the FDA put this thing out. You can buy ketamine over telehealth and they'll send you oral ketamine in the mail. It's pretty wild, this is DA listed substance. There's no oral ketamines that have been approved. FDA put this warning out October 10th, that was two weeks before Matthew Perry's death. This was a podcast that Sanjay Gupta put out, I dunno in the last few weeks, the wild west of ketamine. And the people who was interviewing were saying, look, basically these companies that just create these loopholes here. So I point this out because as if you wanna work in healthcare, I think it's really important to think about when companies and innovation align with improving medicine and improving patients and when it doesn't. And I think there's a lot of times where aligns you know most stuff, innovation in medicines and imaging and surgeries, value-based care often aligns. There's times when sometimes it just doesn't align. These third world diseases, maybe there's not as much spend on it 'cause it's not American dollars. Preventative care we're terrible with. And there's times when it actually maligns and I just wanna point this out, we should always step away and not just assume because we're making money, it's aligned with health with what's best for healthcare. We wanna feel really good about what we're working on. So the cure versus treatment argument, it's better. You can make more money treating a chronic disease and curing it or hospital capacity, disaster preparedness, we should be, hospitals should be 40% full, not 99% full, but hospitals make money by being 99% full. Maybe you can argue some of the telemedicine things that are happening now are also maligned against what's best for patients. So the next step away is if you wanna be able to, for me at least get through all of this hard slogging work to take many years you have to have a north star and that north star should be our patients. You can have one north star, you can't have two, you can have many goals, you can try to make money, et cetera, but you need to have one north star. And to me that north star motivation has been super, super powerful in the hard times. How are we doing with time? Perfect. So here are a couple slides just from one of the MD Calc decks. I thought I'd just share how we describe MD Calc and it'll also get to our evolution and some other things I've thought about with it. So MD Calc central role in evidence-based medicine, the way I try to describe this to non-physicians is back in the eighties and nineties, more or less what doctors didn't make decisions by trying to remember what they read in a textbook sometime in the past. And then chest pain went to the left. So I guess that's, this is that ACS or they try to remember the last few patients they saw. And over time we've developed something called evidence-based medicine, which is statistically sound ways to measure and make better decisions for patients. And one of the core problems or challenges I would say is this is better for patients. Evidence-based medicine is much more scientific. But one of the core problems is that the folks who are good at the statistics of evidence-based medicine are actually not the clinicians. See, I'm using the same pictures as before. So one of the things that I think about a lot in MD Calc is how we can make these hard ideas approachable for clinicians but not make it a black box. They'll teach them what they need to know so that they can apply it and help their patients the best. So that's what I think our best, our really important role here is and has been successful is just to be that bridge from some types of evidence-based medicine and make it approachable for clinicians. And then over time there's been more and more decisions that have been driven by the type of rules that are on MD Calc. And you guys, as doctors know, we have tons of types of tools in MD Calc. They're all clinically based and better for patients, which is what I love about that, the north star's right there. But there's a lot of different value props across different tools. Some are great for value-based care, some increased quality metrics, et cetera. So there's a lot of really interesting value props as a business that MD Calc can give to different sectors of healthcare. While all of it improves health for patients. So the evolution of MD Calc again 2005, we're almost 20 years old now. We were just trying to solve a problem. We were not trying to start a business. And that's I think what made us make it through all these years. Pretty soon early on we became synonymous with medical calculators and there's only 40 to 50 clinical tools at the time. And then soon after that I think we kinda got lucky. We're first movers in some ways. But also I realized that as this world of clinical tools started building and more and more specialties started and more and more clinical scenarios started developing the rules that ended up on MD Calc, we started trying to figure out how we as MD Calc can improve the process too. So we started working directly with the calculator creators and other experts and work with them to drive the right kind of information to the practicing clinician. And what we found over time is there's this virtuous cycle would be created where we would think of ideas on how we can improve that bridge from the clinical tools to the physicians and be folks who are working on the research would then react to it too. And we worked closely with them and pretty soon more and more opportunities started appearing for us. So we got lucky in a lot of ways. But I think part of that luck comes from us trying to constantly figure out how to make things more excellent. So we didn't actually launch our apps until 2016. There was apps that existed called MD Calc but within a year or two the Med-Calc app stopped supporting themselves. I think they just took it a lot less seriously than us 'cause we were just driven to make these things as best as possible. Started partnering with medical societies. They started reaching out to us during COVID. Operation Warp Speed tapped us for this really cool project where we launched clinical scores to help with deciding who should monoclonal antibodies. We thought Warp Speed was gonna make that the main way of determining who would get the vaccines. And then we all know how the vaccine rollout happened per state and it was a mess but really, really interesting opportunity started coming to us and I look back at it, it's because we were constantly trying to improve what we were doing in a very north star way. Everyone was focused on the north star in helping patients. So my two other takeaways from this and what's led to our success is that when opportunities knock, be ready for them so you can answer the door, which is an old saying, but also you can sometimes create those opportunities, especially with these virtuous cycles. So if you're constantly trying to figure out how to make things better and maybe you come up with 10 ideas and nine of them are terrible, one of them is good, you can innovate in that way. And when you start building in that virtuous cycle with other like-minded focused folks in your industry, it can really, really scale up quick. And I think that started happening to us sometime after 2016 2017 in a much more virtuous cycle. And part of it also was that the folks who had trained under MD Calc were now coming mid-career and that became really grew our use as well. So here is where we reached scale-wise. This was a survey done by a growth equity fund that was trying, was looking to potentially invest in us. And they went out and did this huge survey of US physicians looking at which medical references they thought of, all the medical references they could look at and how which ones were used. And only four of them were used by more than 50% of doctors regularly, which is the last three months. So it's UpToDate, Medscape Doximity and us. The name that surprised me or as an emergency doc a little bit were Medscape and Doximity and part of it is that Medscape has been around for a long, long time and is used broadly, but also these two medical references sent out a lot of emails to keep folks coming back in. So it's not always people coming straight to them. UpToDate did not surprise me. A friend of mine who runs a medical international medical organization actually was looked, I was showing him this recently and he pointed out we look internationally, he was saying I wonder if MD Calc might be number one or number two 'cause Doximity and UpToDate drop off 'cause UpToDate's not as a firewall there on that. But we haven't done that yet. And something I wanna point out about how long of a slog it is to build a scale, at least in these type of medical references that you need to be in physicians' minds is you can't do it overnight or I've never seen that really these are old, old medical references to get across lots of specialties and get across all the age range of medicine. It's a long, long path. And that's why I'm pointing out all of these really important things that can create your motivation and drive forward, creating virtuous cycles, but also keeping you focused when things are really difficult. Some other data from here, this is what they call an NPS score, which is what the users see as the value of your tool. So we were second to UpToDate and both of UpToDate now's much higher than everyone else. And all the other companies that looked at were below. The scale goes from negative 100 to 100. Here's another version of that with the actual app where we were actually number one across these, but some of these aren't really used as an app as much. And this is pretty neat. This is actually a recent thing that we just got, can anyone guess what MD Calc has in common with Tiffany's, Coca-Cola and UPS?

- [Karan] Associated with the color?

- [Zaid] Yeah, you don't need the logo.

- [Joe] Yeah, so to actually we have a, these are all trademarked colors so the patent office has now given us, so you have to prove to the, you have to show to the patent office that just the color people in your industry know who you are. So a lot of companies aren't able to do this. It's just a badge of honor for me. I've been working six years and we just got this a couple months ago. Yeah, so, blows our mind a little bit. We weren't really totally expecting any breadth of use that we now have. And of course the internet and sort of first movers has helped a lot. But I think a lot of it has been this virtuous cycle and us constantly trying to just push the envelope. We're now used by millions of doctors take care of hundreds of millions of patients. And that keeps, that's our north star there. I really think we could just do so much more in how we can help patients through platforms this. And if you're focused and build on top of your platform, think that's becomes very powerful. Ans so just to summarize my four takeaways, number one, it's a long road. Try to choose something that you love, you love what you do, have that north star motivation and you can one up Carnegie, if you guys know Andrew Carnegie this quote, I'll show it in a sec. Increase your chances of good luck, that's the opportunity knocks answer the door. But you can increase your chances of having those opportunities and always try for excellence that actually works with a virtuous cycle with increasing your chances for good luck. And just do that over and over. And so Andrew Carnegie is seen as by philanthropists as this model and he has this quote, has anyone seen this quote before? Try to make as much money as possible in the first half of your life and spend the second half of your life giving it away to do the most good and the least harm. And I would argue if you can work in healthcare and you can pick in healthcare an industry that's aligned with what helps patients, then you're skipping to the end. He's make a lot of money so later on you can help people. And if you can do that now this is what's so, so cool about, I think working in healthcare is that you can help people today while you're building a business. So I feel super, super lucky that I feel we've landed in that space with MD Calc.

- [Karan] Amazing.

- [Joe] That's all I got.

- [Karan] Thanks so much. We already got a bunch of questions in the chat, but one thing I just wanted to say before we get to the Q and A is I really framing it as a north star motivation and then many goals because I think when you're starting something it can feel so overwhelming 'cause there's so many factors to consider in a place that's as complex as healthcare, but having that one north star, not only if you're starting a company, but for those people that are in the hackathon, when you're refining a pitch, I feel having that north star and knowing, okay, this is what we're actually trying to do and this is who we're trying to help helps even at that early stage when you're just trying to figure out what you're doing, having that north star is really helpful. So I love that. We have a bunch of questions in the chat. I don't know if Max, you have one here about how you got how Joe and Co got MD Calc in front of training MBs. I don't know if you wanna unmute and ask real quick.

- Yeah, I think I'm just kinda asking about that well the whole all phases, but mainly that grassroots phase of how are you finding, what are some tips or how are you finding those champions? what ways were you pitching to physic these younger physicians or how are you getting people stoked?

- Yeah, yeah.

- Building because I assume what you mean it was you were just building product that you, or something that you guys wanted to use that was just trying to solve a problem. You didn't have a business in mind yet, which I think is awesome and I just how?

- Yeah, yeah. No, you're right. No, we didn't have a business in mind. I'd done my MBA and I was , maybe I'll work on a business, but it wasn't to me about a business necessarily. It was just, I need to get the skills to figure out how to build things. What I didn't about medicine. The only thing I didn't really about medicine was that it didn't have the math and it didn't have this idea that you can sort of just figure out your own way. I love that entrepreneurial feeling, but entrepreneurial sounds like business and I don't mean to say that. I mean let me think of an innovation, let me figure out how to make things better and see a problem. And so that's why when I met Graham, I was like he's fixing problems in math. This is so, so cool and I can drive a lot of value. And at the time it was, there're just such a need because there's these clinical tools that people didn't really know. There's several examples you might even know them where there's two tools and one's more sensitive, more specific, it's a better tool for patients and the other one's easier to memorize and people are using the one that was easier to memorize. We were trading off our own comfort and memorizability for patient care. I mean that should not happen. And so we thought, all right, there's gotta be a better way to do this. And so just making it a overly simple and approachable thing, knowing that most doctors can't approach are nervous to approach things make it clean and simple. And it grew on that. I mean, people liked it so it wasn't hard to get people who are excited about it to work on it with us and we really liked it. And I think, and I still really like it and I think that is really helpful for anyone on our team 'cause they feel how excited I am about it and that that drive, and so everyone we work with is like that. And if you could find like-minded people, I don't think it's, it kinda just builds on itself. Yeah. So I don't know where to start. I guess it's to find the problem and fix the problem that is a real problem is might have been.

- Yeah, I think a business often is a solution in search of a problem which works and has worked forever. But that having the ability to do something grassroots where you're just trying to solve something and just trying to and again, you are customer one kind of yourself is very cool. So yeah thank you.

- Yeah, no thanks thanks. I mean the other business I had there, UpToDate started like that too. It was a physician who was like, I can make the version of the textbook that sits in the hospital better and then my understanding of that story as well, so

- [Karan] Yeah.

- Thank you for the question.

- Shriram, I think you had one. If you are in a place that you can unmute, that'd be great. Otherwise I can go ahead and ask it as well. Okay you're on a shift, I see that.

- I love it.

- All right, well just so everyone who may not able to see the chat can take a look. Shriram is just asking, in your opinion, what role will AI play with high stakes decision making through tools like MD Calc and the ED? And I think that's an interesting question too. Partially because one of the things I really love about you can see the evidence, you scroll down below the decision tool and it's really easy to see what evidence it was based on. You see the creator, you see what paper is, et cetera. And I've been on shift in the ED playing around with using AI using the chat version of GPT as well. And one of the things that's hard is that unless you're really refined with the prompting and specifically asking for sources, you're not really getting that kind of source material for those people who wanna look beyond and see what the evidence is. So that's a little add-on to Shriram's question, but I'm also super curious in what you think about AI and clinical decision making right now.

- Sure yeah, I mean I think it's a really interesting and exciting time in ways. I also think it's we have to be really, really careful about it and one of the approaches MD Calc has been really careful about is not disintermediating the relationship between a doctor and a patient and not trying to replace the judgment of a doctor. And what we find is when docs try to stop thinking and just outsource their decision making to a clinical tool, and this has been a problem not with a, this has been a problem with clinical scores forever. And we try really hard to not do that, to give the right light to the doctor so they understand and aren't intimidated so they can understand what they need to understand, they might not understand as well as the statistician, they need to understand certain aspects of it. AI, but the thing is people are lazy and doctors are people and that becomes a very dangerous potential spot I think. So I think we have to be really, really careful and we are trying to be really, really thoughtful with this stuff now. MD Calc's into this really interesting position because we're used again by, I don't know, something like 80% of doctors will use us, it's about two thirds that will use us regularly. That includes some specialties that don't use us at all. And my mother who doesn't know who, 85 still practices, doesn't know what MD Calc is so it's a lot of doctors and we are the most clinical toolish kind of thing. So I think we have a lot of potential, we can lead in this way and we're trying to be really thoughtful in how we think through and lead in that. But that's a great question and we'll see how it evolves.

- Awesome. And we've had a few more still Shriram that we'll come back to your follow up in just a second. Kim's had a question for a little bit. I don't know if Kim, you wanna unmute and ask a little more about the organic physician growth?

- Yeah. You said in your 15 year mark when you're at more than 50% physicians that you had grown that use space organically. So I was just asking a little more about what you mean about that organic growth 'cause that's a lot of growth and usually there needs to be some accelerant to create that snowball. So just a little more curious about how that happened.

- Yeah, yeah, I get that. And we literally haven't sent out any marketing emails. The majority of the medical references, I think it's UpToDate and us that can get these numbers without constantly pushing out clickbait. It's what Medscape and Doximity do. And all I would say is about it is we weren't really focused on growing, we were just focused on making something really, really helpful for doctors and then working with folks who wanted to do that. So as sincere as that is, it's just , it was a north and every step of the way we're how can we get this better? How can we find other fantastic people who wanna make these things work better? And then our brand was lifted with that and then more and more of these tools were coming out and then we started, now folks are publishing tools and they're reaching out to us are we ready for MD Calc? And we're already working with them very early on in this process or, and they'll sometimes tell us, we, I got into doing these research because MD Calc is will help bring it to the bedside. So we started realizing we were helping them with their, they weren't just giving us the tools to bring the patients, but vice versa too. And so I think it's just being open to work with other like-minded folks at the same time, but it's just been organic. I think now, most people are just learning about MD Calc pretty quickly on the wards or just downloaded it before that at this point. So, but yeah, no, it blew our mind. Part of it though was just the age thing. It took this many years because most people do what they learned in residency and so that takes some time and then now you have those docs who didn't train during MD Calc and are using MD Calc, but that takes a long time to spread across all the specialties in medicine.

- I resembled that comment by the way.

- Fair enough.

- Hey Zaid, you said you had a question. Just wanna give you a chance to ask too. Oh, we got--

- Oh, I love it.

- Yeah, this is the jealousy part I was telling you about, Joe. Now they're fighting for space. Thanks for this awesome talk. When you were thinking about scaling, first of all, as physicians or physician entrepreneurs we're always, it's so easy for us always say yes, yes, yes, yes to every single pipeline and every single branch point. How is it, were there any parts when you were growing MD Calc that you had to be very intentional about saying no, this is not something that we're gonna pursue or this is not an avenue that we're gonna go through both or for improvement?

- Oh yeah, I think I was also someone who just wanted to do everything and I had a lot of ideas and I think over time you start realizing you can't do everything and you have to be focused about it. You also can't partner with everyone. We just realized over time who you wanna work with and people who are like-minded but also organizations that have that top, a similar type of brand equity and stuff. So that's hard. I think learning how to say no is really, really hard. The other thing I think that's really hard with entrepreneurship is it is so much more work than you can imagine doing one step forward probably means you took six steps and five of them failed and two of them pulled you back and finally found something that make it work and so afterwards it seems like, oh, you just did these things and that took a long, long time and I would say 98% of people and 99% of doctors are not built for that. And so, I don't know, maybe I'm blowing it out with that number, but I'm partially saying that too because there's such an attri, it is the shiny thing right now and so something that everyone should think about, it is a lot of work I think. And you try to do everything and you have to go through that learning. So.

- Max, I know you just dropped a question, you wanna unmute and ask and then we can maybe go back to Shriram after that.

- Yeah, mine was just about web and mobile. I'm generally a software developer, so my thing is I hate apps unless they do something really special on your phone. Like they work with your camera or stuff like that. But I mean, it doesn't matter what I hate for you and for MD Calc, what is the split between usage for web and mobile and do you think mobile really helped word of mouth and spread versus web?

- They both have a lot of usage. Web is big because I think a lot of it is just people are still sitting at their computer with the EHR in front of 'em. So the app is generally makes sense. It's younger, it's much, much higher, daily, multiple times a day users. And then there's this long tail of folks who's using us once a week or what have you that are getting into it. I mean, I trained with clinical tools but the medical guidelines now have them so I have to use or you know, what have you. So, but I get what you're saying, everyone has all these preferences so it's how do we deliver a similar clean, easy interface across these?

- Yeah, I mean I think it's more just yeah it doesn't matter about my opinion, it's just if people like apps then you gotta make an app, cool.

- It's something that we weren't even meaning to do but it really helped us consolidate the eyes was there was an app and there was a website so people had, people would think it was the same company we were this, we were the website and there was this app called Med Calc. It didn't look like us, we were already working with all the creators and writers and stuff we're just much more academic I think we just took this just were more focused and constantly trying to improve it. And so launching an app within two years, we kind of consolidated that those eyes again, we were just we're like all right, enough people are asking about an app, we need to make an happen at the time. But that's funny. But yeah, 11 years in that we did that.

- [Zaid] Sorry for the interruption Joe. I was gonna say for me they satisfy two different use cases. The website for me is my, what I'm sitting down charting so I can copy paste.

- Yeah.

- [Zaid] But then the app is for my patient education where I'm in the room with them and I can show them what guided the decision. So it's--

- Right.

- [Zaid] They occupy different needs.

- Yeah, yeah, we hear that. We hear that a lot too. Or we hear some people are looking for something and they don't realize it was on MD Calc and so you're using the app a lot and it's something they're online, they're , oh and it's MD that's on MD Calc too. And so they'll cross over to here.

- Yeah, we see that too for both. I mean I 100% agree with that in terms of MD Calc usage. In our department we also have a clinical information hub, a digital one and also has an app view and a desktop view. And it's just, it's really interesting to look at the user data and see which guidelines are used in which views 'cause it depends on the clinical context. A lot of our trauma guidelines people are pulling up on their phone in the trauma bay, but a lot of our other regular clinical guidelines are all desktop. So it just depends on the user behavior, which we've seen too, which is super interesting.

- Yeah, yeah, yeah totally.

- Okay, Shriram, let's get back to your second question. Know you're on shift so I'm just gonna read it and we have a few minutes left for more questions. And Shriram was mentioning for future medical LLMs, any version of ChatGPT or analogs, how do you think about balancing scaling with data security and compliance basically patient privacy concerns and that's I guess you're not giving in the current version of MD Calc granular, individualized patient data, but that might be something that happens more with these AI apps.

- Yeah, I think we have to be really thoughtful about that. I don't have, I mean these are the dangers. I think the clear landmines here and people are gonna throw a lot of stuff out there and we have to be really, really thoughtful as physicians. We have a lot of responsibility to do what's best for our patients security wise, but also decision wise. And so I think we just have to be really, really careful as we move into this new space. For sure.

- [Shriram] Hi Dr. Habboushe. I'm not sure if I'm pronouncing that name correct. Thank you so much for that answer. So I have one more question if you guys have a few more minutes. I have a couple of friends who are developing their own apps and hardware solutions and they have a hard time gaining institutional buy-in. So what, in your early stages with MD Calc, what did you guys do to get more institutions to use it? More people to try it out because most people without the manpower or the contacts are gonna struggle with new hardware or software solutions.

- I think you're pointing out one of the hardest things in this space, this health IT space that wants to connect into medical systems. The medical systems are really hard to work with. Really, really hard to work with. So they're risk averse, there's a ton of stuff. A lot of the stuff out there is is like smoke and mirrors and not high quality, so this is a real, real well problem. So I think it's a difficult one. I don't have a silver bullet to it. So it's a problem that every organization has dealing with medical systems like that. I think what has helped us is that we just built a really, really valuable resource. And so it's going back to really trying to solve a problem and doing that well. A lot of companies that depend as a business on integrating into medical systems fail 'cause they can't scale 'cause they can't scale fast enough. And they just don't know. They don't understand how long and long, long, long it is and how little money you can make unless you have a real financial clear, clear financial ROI. And so you see a lot of startups either trying to pivot or running outta money and stuff that.

- [Shriram] Amazing, thank you so much. Also, very coincidentally I received an email from EMRA today. You're copied on the email. We're working on updating the basics of EM guide, so.

- That's awesome, you're one of the authors?

- [Shriram] Yeah.

- Cool.

- [Shriram] Thank you.

- Yep, yep yeah, thanks for being part of it. That's great.

- [Dhruv] I had a quick question. So when you're developing a product, it's obviously critical to try and predict how it's going to be used, but, and you probably scale it to, you probably scope it to something that's going to be successful, through investors. But once you have the product that's established, how much goes into predicting continued methods of use and how much goes into driving people to use it in the ways that you can maintain and how much may go into trying to develop new ways to access your product or new ways to use your product. How do you balance those three ways of scaling your product?

- Yeah, I mean I think companies do it in lots. Those are all good ways that you can try to scale a product for sure. And companies do it in all different ways. Our approach tries to, our way of thinking about it is just try to drive something that's very valuable so that folks want to come to us and feel like they need to come to us and trying to understand how we can continually do that better and better for what it's worth. But you see a lot of companies have, we don't spend money on marketing mostly we spend, we're starting to a little bit, but it's not, our value's to make really, really great products. And then, then it's word of mouth through our users and getting them to communicate with each other. Trying to activate that. But you see companies that do it in so many different ways, right? There's other companies I had that had over 50% reach, spend a lot of money on marketing for sure.

- [Dhruv] Thanks.

- I actually have a question. I know we only have a couple minutes, so I am intimately familiar with how time demanding residency is, and this all started when you met Graham in residency. And I, you were talking about the moment where you find alignment. You found obviously he was someone that you were interested in collaborating with. You loved the idea 'cause it combined that math part of your brain, the business part. What was the, you talked about aha moments, what was the aha moment for the two of you? Did you have a single moment or was it more of a we want to build this product for our own use and it just kind of gradually snowballed from there? Or did you have a single moment where, maybe another physician from one of your attendings or another hospital system was like, hey, can I use this? Were you like, oh, this could be a scalable thing?

- Yeah I think it was already getting used pretty early on by academic nerds in a few different specialties across a few different tools, right? And that's where it started. And we realized that people who used it felt that there's value in it and it's simple and easy and this is clearly a trend in medicine. I mean, clinical tools were new, you compare us with a drug reference or something, drug references are old. My parents carried around a PDR in their white coats. But clinical, these things are new and so we saw that, we're making these easier to use, we're solving real problem here. There is a lot more benefit we can do if we may, if we just really focus on and being really thoughtful and intentional about making this better. And we were hopeful and predicted that there would be more of these tools over time and that it was clearly the beginning of that process and took a few years out. But then it started just the number of the tools that we're gonna, in the literature started really accelerating as well. So it just felt like we had enough there of this is, we're hitting on something that's valuable for folks. So we can, if we're, let's pay attention and focus on it and if you're excited about it, it doesn't feel like work. You're just doing it all the time. I'm sure everyone here has worked on projects that they love, feel that. So I'd encourage definitely leaning into that.

- Amazing. I love it. If anyone else has any last minute questions, feel free to unmute or drop them in the chat. Otherwise, I wanted to really give you a big, big thanks to you, Joe. Thanks for joining us, amazing lecture. This is gonna be recorded and thanks to everybody for such a great Q and A people, for being engaged and all of the great questions. Connor, thanks for joining from the MD Calc team. I think Connor's gonna be in touch with folks for how to get your MD Calc swag. So look out for that. But unless somebody has something last minute, really appreciate everybody coming out and we'll be in touch with the recording once that's posted. And for those of you in the hackathon, only a few weeks left until ACEP so we're really excited.