Entrepreneur RX_Subha Airan-Javia: Audio automatically transcribed by Sonix

Entrepreneur RX_Subha Airan-Javia: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

John Shufeldt:
Hello everybody, and welcome to another edition of Entrepreneur, where we help healthcare professionals own their future.

John Shufeldt:
Hey, everybody! Welcome back to another episode of Entrepreneur Hour. This one's been a long time coming. Subha, I have been going back and forth as we finally got our times together. Dr. Subha Airan-Javia is a fellow of the American College of, actually, what is it?

Dr. Subha Airan-Javia:
Fellow of the American Medical Informatics Association.

John Shufeldt:
There you go, she's a practicing hospitalist and informaticist at Penn, as well as former associate chief medical informatics officer for the health system. She's spent the first 15 years of her career working on designing and building technology to help teams work better together and make sure preventable errors do not happen. So as part of her work, she and her team created CareAlign, which we'll talk about a lot today because it's a really cool platform. It's a platform that's deployed across Penn Medicine, which is totally amazing, for more than a decade, for which she spun out of Penn as well as a startup a few years ago, and now she works full time as a founder and CEO of that company and still sees a few patients a week, which is amazing as well. Her mission is to make it easier to do the right thing for the patients. So with all that, Subha, welcome.

Dr. Subha Airan-Javia:
Thank you so much for having me, John. I'm excited to be here.

John Shufeldt:
Thank you. All right, so let's start at the beginning, because when I was researching you and looked, you don't have a background in bioinformatics or really in tech. How did you, go ahead and start from the beginning, like, how did you end up here?

Dr. Subha Airan-Javia:
In the beginning, I was born in Miami. Okay, yeah, so I definitely have a curvy road as my career path. I went into medicine, actually fully expecting to be a surgeon, and found my way into medicine through some really great mentors and role models and then was convinced I would do cardiology or critical care. And you're right, I don't have a tech background, so I've just, I do have an information systems minor in college, but I've always loved technology. I've always been an early adopter of technology. In medical school for some reason, my nickname was Computer Subha, so it gives you an idea of how I've always been that person, but in intern year, I was really struck by the inefficiencies of how we work together as a team. We were using paper lists to keep track of who needs to do what and how to communicate, what needs to happen at transitions or at shift change, which spoiler alert, is still the gold standard everywhere in the country. And I learned very early that it was very easy to make mistakes, and that really resonated with me as something I wanted to work on. So at the end of my intern year, I basically went to my program director and asked for resources to make a better tool. Long story short, she agreed with me. She got me resources to work with our IT team at Penn. I don't do the coding, I do the design and really bridge the technical and the clinical use cases together, and we developed what's really the grandparent of CareAlign, this is back in 2005, which was a web-based platform to replace what we were doing in Word, and it had some information automatically imported, but it replaced a lot of what we were doing on Word, and it took off across 3 or 4 residencies at Penn. And I would get comments from people saying, wow, this has made it so much easier for me to do my work. And that was the first aha moment for me that helped me realize that my ability to improve care and improve lives or impact lives was exponentially greater through technology and systems improvement than through direct patient care, which I still love, but it really became a calling for me. I decided to not pursue fellowship and instead to go into informatics. At the time, Informatics Fellowships, there were very few and far between, and my husband was a resident, so I wasn't going to move, so I just lobbied for a job at Penn to be the informatics physician on the inpatient side. But that's really where this all stemmed from, is saying what are the problems and what we're doing, what needs to get fixed? I guess you could call me a problem solver and someone who really dislikes inefficiency, and I translate that into designing tech that's easy to use. I firmly believe we shouldn't have to force clinicians to use technology. We should design it in a way that they want to use it and apply that to providing better care for patients.

John Shufeldt:
It seems like you're one of those people, because I count myself in this where you say, wouldn't it be cool if? Now I can describe if, but I can't program, but I can put it down on paper and say, if you can build this, I can describe it. And so it sounds like that's what you're doing, that's a really cool. I mean, and you were, why were you pressing to do that in 2005? What system was Penn using in 2005?

Dr. Subha Airan-Javia:
At the time, we were using Allscripts for inpatient EHR, Epic for our outpatient EHR, so they didn't talk. Cerner for our labs, and a whole host of other things. So we built and implemented CareAlign first before any of those brought together.

John Shufeldt:
Really?

Dr. Subha Airan-Javia:
With ... and Cerner, yeah.

John Shufeldt:
Wow, I have good familiarity with two of those, not with Epic. I've never used Epic, although I hear that's probably one of the easier ones to use as far as a clinician goes.

Dr. Subha Airan-Javia:
I think that, I'll just say that usability has a long way to go in all of our electronic health records, and I've actually never used Cerner on the clinician side. I've talked to hundreds of people who have used all of them, and they all, any time it takes eight hours of training for you to be able to even get started with something, I think that's an indication of how easy it is to use.

John Shufeldt:
Yeah, or how, yeah, exactly how not easy it is to use. I spent a lot of time in tribal medicine and they're using a system there called RPMs, which is a legacy VA system, which is basically Dos-based, that's what it feels like. It is, literally, you had carpal tunnel clicking one chart to get, you know, I remember I was ordering a medicine that took me ten clicks to order one medicine.

Dr. Subha Airan-Javia:
I believe it.

John Shufeldt:
It was just like, I just got just shoot me now. It's so inefficient. Where do you see, or how do you see AI influencing what you're doing? Because it seems to me there would be a lot of things that you could use generative for AI to help even streamline and augment that even more.

Dr. Subha Airan-Javia:
Absolutely, I think our ideas of how we can use it in and of themselves are exponentially increasing as we learn more about it every day. There's all sorts of things. There is, I think the two things that people talk about most, usually, are using AI to summarize information and help you find information about a patient, and then the second would be for generating documentation. That's what people typically talk about. I think there's definitely a lot of promise there, but a long way we have to go to be able to validate and be able to use it in that way. Part of the areas that I'm really excited about are using the things that we learn about how clinical teams work together and the patterns of behavior that we see of what people do when they're caring for patients, getting insights from that and using these generative algorithms to first understand, oh, this is what we predict will happen based on the behaviors that we're seeing or the workflows that we're seeing people do, so you get those insights, and then you can help influence what people do next. So it's almost like using our system as a way to feed it and to learn what to do and how to advise us to do better, but absolutely, the, making it easier to document is always top on our mind.

John Shufeldt:
Stepping back a little bit, you've done something that's really difficult and kind of unusual, you've started something in a university system and gone through this tech transfer process with the whole cap table and ownership and IP, and now move it out into the free market. How was that experience?

Dr. Subha Airan-Javia:
It's funny, when I read your description of the podcast, I was like, this is so perfect because, I tell this to people all the time, that I think every physician should get the basics of business education. And I think one of the biggest reasons that we are not at the table for decision-making in health systems is because we don't know how to speak that language. So when I started this process, I literally knew nothing about it. If you were to think of how I felt as a first-year medical student is really how I felt when I first started the business. I had to look up every other word. I would, no joke, be in meetings, Googling what's cap table. What is security? What is a convertible note? What is a runway? So this was all truly drinking from a fire hose and made a lot of mistakes, as we all do when we first do things and you learn from them. So it was complicated, it was a learn-each-step-as-you-get-to-it type of thing. It was also fairly new for our health system because I think most universities are set up around commercializing molecules and devices and not as much around software. So there's a lot of gray area around, where was the intellectual property for that? Where was the investment for it? So that was interesting. The piece of advice I get most is, make sure you hire your own attorney, not just the counsel for the university and not just the counsel for the company you're making, but someone just for you to look out for and advise you on your own personal interests.

John Shufeldt:
That is really sage advice, and that was a mistake I made years ago now, but I was like the Three Musketeers, one for all, all for one, so we're all thinking alike. And boy, was that a mistake, because that ain't how it shook out. What do you think stops physicians from, you know, I would call it building the wings as you fly, and for, is it, do you think you're born with this, or do you think you just say, what the, you know, screw it, let's do it sort of mentality and figure it out as you go? Because I see what you described as a real barrier for a lot of our compatriots. I just don't, I like knowing what I know, and if I don't know it, I'm not doing it.

Dr. Subha Airan-Javia:
No, you're absolutely right. It's a good question. I'm a, in the nature versus nurture conversation, I'm more in the nurture boat. But I'm, I mean, I'm sure there's probably something in the you're born with it, but I really think that we are very influenced by what we experience and what we grow up with. I had parents who were business owners. They ended up filing bankruptcy from one business and then did a whole nother business, did night Law School then built a whole law firm, and I think a really important attitude that they taught us growing up was, if something's wrong, then you should try to fix it, and just because it's hard doesn't mean you can't do it. And fundamentally, you can do anything, you just have to learn how to get there. So all of that together, I think that was a lot of the motivation of it's okay, I don't mind challenging the status quo, we'll just, we'll do it. Separate from that is risk-taking, I find a lot of our colleagues are very risk-averse. Having only been a physician and now an entrepreneur, I don't know that my sample size is well enough to be or big enough to say that I can say that for the entire population, but it feels like there's a lot of risk-averse people in medicine.

John Shufeldt:
Which is probably not a bad thing in some specialties.

Dr. Subha Airan-Javia:
Yeah, it's true.

John Shufeldt:
So it sounds like this is interesting. It sounds like you basically had this, you had this education at your dinner table. You got to witness your parents going through success and failures and just total grit.

Dr. Subha Airan-Javia:
Absolutely.

John Shufeldt:
Pretty unusual. So, yeah, no, you're right, it sounds like very nurture and obviously some nature, too, because they created you, and that's kind of who they are. But it's interesting because you start in this tech field as a young female physician in 2005, before, I would bet you at that time, most of the informaticists were men in medicine. I would say 90%.

Dr. Subha Airan-Javia:
I'm sure, I don't know what the actual number is. There's still an underrepresentation of women in tech everywhere.

John Shufeldt:
Yeah, you were really an outlier, that's pretty cool. What advice would you have for everybody, but for maybe women in particular, who want to follow in your footsteps? Because as I told you, there are people who listen to this and say, I want to be her when I grow up.

Dr. Subha Airan-Javia:
Yeah, I love that question. I think that, I mean, the biggest one is to go for it and to find a mentor or find an ally who will help advise you and be your cheerleader. So many experiences I've seen have been affected by the people around them, and I've had a lot of great mentors, a lot of great supporters around me, there's definitely been some of the others, so you just try to not listen to those and focus on the ones that can help you. But, I guess fundamentally remembering that literally, you can do anything, and never let people tell you no, and just find someone else who can help you get on the right path of how to get there. One great thing is now there's a lot more funding opportunities and support for minority founders and female founders, especially minority female founders. It's also something to talk to your council about because how you structure your business and perhaps being able to say this is a minority, female-led business, or at least to get that certification which matters for some types of contracts. But yeah, the biggest advice is, do it, and that's for anybody. Do it and don't be afraid, and remembering that if you make mistakes, they're not the end of the world. You will learn from them and do better the next time.

John Shufeldt:
It's funny, I was just talking to somebody really recently who just, I have a tremendous amount of respect for, and they told me, they said, it was, it's a woman, and she said she suffered from imposter syndrome. And I said, yeah, me too. I think everybody suffers from it, I mean, unless you're one of these, and it's not like this is a rare thing, but unless you're one of these very ego-driven, and I hate to say it because it's probably more men than women, I think most of us, I think a little bit of imposter syndrome is a good thing because it keeps you on your toes. I got to keep up in my game just to keep up with folks. Did you feel like you've had that, or you have that?

Dr. Subha Airan-Javia:
Absolutely. I think you're right, most of us have some element of it. There is a lot of research that shows that women tend to take the plunge later or take the risk later, where, meaning only when they have nine out of ten of the qualifications for something will they apply for a job, whereas men are likely to apply if they have, I don't know what the number is, but four of the ten one. So guess that would be a piece of advice too, is to say, you know what? Everyone feels like that. Everyone thinks, oh, I don't really know that fit this bill, but if you're excited and you're passionate about it, go for it. But yeah, I think I know very few people who don't regularly wonder how did I get here? Am I the right person for this? I really, I know you mentioned grit. I love both Grit and Mindset as two books that are informative and impactful in how I think about things and how I teach my children to think about things. And at the end of the day, it's you can do anything, and if you can't do it now, you'll learn how to do it. And the second is, it's not going to be right the first time. It's going to be hard. You're going to make mistakes, just keep going.

John Shufeldt:
Yeah, it's funny, I was watching my kids grow up, and I have these two kids, and I always tell them to this day, they're the people that I wanted to be when I was their age and I wasn't. But I would watch Michael, who's a entrepreneur, fighter pilot in the Air Force, when he was growing up, if he had a 10% chance of getting it right, he would have his hand up like this, and he'd speak with just absolute confidence. My daughter, who would, you know, is a straight-A student through college and grad school and high school, unless she was 100% sure, maybe 110% sure she had it right, she would not raise her hand, and I'd always harass them both and maybe they should combine a little bit, they would do better. Michael never lacked for confidence, and he was often right, but Kaylee was like, man, no way I'm raising my hand and put myself out there unless I'm 100% sure. It's really a funny dichotomy.

Dr. Subha Airan-Javia:
It's so fascinating. First of all, thank you to your son for his service.

John Shufeldt:
Oh, you're a rock star, thank you.

Dr. Subha Airan-Javia:
And yours, by association, I don't know if you were also in the military.

John Shufeldt:
No, my father skipped me. Father and son and actually son-in-law as well, but yeah, they're cool.

Dr. Subha Airan-Javia:
Your family is also your service, so thank you. Yeah, it's amazing how early kids learn these types of behaviors, and it sets in really early. It's part of why I'm such a nature versus nurture believer because I think we teach children through all sorts of unconscious ways that they should behave like that.

John Shufeldt:
Yeah, it's funny, my daughter literally just pointed this out to me last week, and she's, things you have said in the past, if you take them this way, they're not all that positive. And until she's what should have been one of those things for me, I like to think of myself as aware, but I was like, oh boy, I never thought of it that way, but you're right. If you're in this construct and you hear this, you're not, it's not going to be a net positive for you. So it's funny, I really have to be careful of the impact of what we say, however meaningless we think it is, and some people may take it as either hurtful or a negative connotation. And I'm like, yeah, good, you know, 62, I've got a long way to go.

Dr. Subha Airan-Javia:
I think it says a lot that she felt comfortable sharing that with you, so that's great. If this actually applies in medicine as well, is that we, it's actually, one of my areas of research is stigmatizing language in clinical documentation, and what does that do to perpetuate bias in subsequent interactions with a patient? We have a manuscript we're working on, but we looked at stigmatizing words, and how often they're found in documentation, and in what kinds of patient characteristics, and not a surprise, minority patients and transgender patients are much more likely to have stigmatizing language usage in their charts. So one of the things that I love about having this business and being able to make decisions about what goes in there is actually, just this week, we implemented stigmatizing language nudges in the application, which basically I'm starting. Like I said, you don't always get everything right the first time. So I'm hoping we'll continue to make this better. But we're starting with the list of about 30 phrases and words where if a person writes them in the application, they'll get this little nudge, and it's meant to be unobtrusive and easy to make it easy to do the right thing, but a little nudge that says, hey, this word or phrase can perpetuate this type of bias, you can use this instead. All you do is click enter, and it'll replace it. And then, we created a resource page to teach people because not everyone is as receptive as you are to your daughter about this. And a lot of people are like, I'm not biased, but that's the whole point is implicit means it's unconscious. And even if you aren't, it's also about the reader of your note and how they're going to interpret it. So anyways, we'll see. We literally just released it. I'm very excited about being able to bring some of this research and mission into the application. We actually did research like ten years ago at Penn on similar nudges to reduce the use of unapproved abbreviations and found that when we did that in actually in the handoff that I created 15 years ago, by doing it there, it actually changed the behavior of people when they were doing their handwritten progress notes.

John Shufeldt:
Elsewhere, yeah.

Dr. Subha Airan-Javia:
Yeah, and my hope with something like this is just to help raise awareness, start changing culture, start getting people receptive and thinking about, oh, maybe I shouldn't say the patient refused, or maybe I shouldn't call this patient elderly, but maybe I shouldn't say the word addict and start to remove judgment and blame from our language and be more objective in how we describe things.

John Shufeldt:
You went into a little bit. Give me some more phrases or terms that would be considered stereotypes or bias or create this negative connotation. Because now, as you say, this gosh, so many times I've put the word elderly in a chart all the time.

Dr. Subha Airan-Javia:
Yeah, me too. I used to write elderly all the time and.

John Shufeldt:
Didn't think it was a negative connotation, but give me, tell people like some other stuff because I think everybody's going to be like, oh crap.

Dr. Subha Airan-Javia:
Yeah, so ageism is probably one of the most common forms that we see. I want to be clear that when we say an 85-year-old elderly patient, that's not saying that we're judging them, but it can impact the way someone else thinks about that patient when we see them. And probably we're saying that based on how they're moving, maybe they're moving slowly, or they look like they're unsteady or weak, and it's much more useful to just describe what you're seeing as part of your exam, because it might, elderly, to me might mean something different to someone else. So there's ageism, saying elderly, senile, there's a lot of patient blame, saying patient refused something, patient is a poor historian, patient is complaining of blank. Even CC, right, chief complaint, it feels so basic, and I've really actually started forcing myself to say chief concern instead of chief complaint because they're not complaining, they're not trying to be difficult. And they is all of us, right? We're all patients. We're just saying, hey, this is a problem, help me fix it or help fix it. And then there's other ones, a lot of them related to substance use disorder and labeling patients. Instead of saying someone's a diabetic, saying this patient has diabetes, and there isn't a one definitive list. There's a lot of research happening now about what is stigmatizing. It's really hard to prove that using a word will lead to problems, that even not using the word will remove problems. But there is some promising research, at least showing that it does change, number one, that we use certain words more with certain types of patients, right? So clearly, there's something there. And then number two, when, in some studies, Mary Katherine Beech, who's an internist at Hopkins, did a really great study looking at prescribing behaviors and other things related to just the words people read in a chart.

John Shufeldt:
Interesting, now I can see where calling somebody homeless in a chart, even though you're basically saying that in my mind, to make sure that other services are available to them or they simply can't go pick up their prescription or whatever the challenge they have, calling somebody homeless does instantly conjure up a stigmatizing.

Dr. Subha Airan-Javia:
Absolutely, I'm so glad you gave that example, because one of the things that really bugs me lately is saying that someone's noncompliant with their medications or fails their medications or non-adherence, and some of these words are baked into ICD 10 codes. They're very ingrained in our systems. Just like when we build technology, and we build systems, we say it should be easy for the user to use. It should be intuitive for them to use. In the same way, I think we as providers have a responsibility to craft a treatment plan that works for a patient's life, right? It's part of why learning about social determinants of health is important because if you can't get to the pharmacy, then I need to make sure I have a good option for you. We say instead of saying patient was noncompliant, saying, I'm not going to remember it off the top of my head, but basically describing that the treatment plan wasn't the best for that patient.

John Shufeldt:
Not conducive.

Dr. Subha Airan-Javia:
Yeah, and this is why I did the nudges because even I can't remember what the right way or what a better way is to say it all the time. So make it easy for me, let me just replace it.

John Shufeldt:
Yeah, particularly when you have 30 patients waiting for you throughout the day to do it, and you're just, rip through it all. Do you think there's a place, for example, someone comes in who's African American, I think the studies are showing that they tend to receive less pain medication when the emergency department, do you think there's a place in what CareAlign is doing to say, hey, FYI, this person's African-American, make sure you're treating them for their pain because studies show that blah, blah, blah?

Dr. Subha Airan-Javia:
I love that, yes. So that would be a next step, is to say this is what you should think about as you're crafting this person's treatment plan and how inequities often pop up for patients of this population. It's a great segue way from where we are now and where we can go with it, all of that.

John Shufeldt:
You see a way forward with our current healthcare system given what you're trying to do, because what you're trying to do, I think, is make charting better for the patient, better for the clinician, more accurate. And it seems to me I hear people saying, great, they'll improve their efficiency. But all this, and I used to be one of them, but all this push towards efficiency really takes away from the physician-patient interaction. So do you see everything through a happy medium where we get this good physician-patient interaction and have the ability to have a much more accurate and complete chart note?

Dr. Subha Airan-Javia:
Absolutely. One of my favorite quotes from a clinician using CareAlign is, I get to spend more time with my patients because I get my charting done in half the time. Or one of my least favorite was an executive, a hospital executive saying, oh, you save people an hour a day, great. How is that going to make me more money? And my response was, your doctors will, and nurses will actually be able to talk to patients, look at data more, think about what's going on, make better treatment plans do better, I mean could think of a thousand.

John Shufeldt:
Turnover less ... risk happier.

Dr. Subha Airan-Javia:
I mean, there are so many. But I think that sums up a real problem in our healthcare industry, which is that the economic buyer in systems is not the care delivery person or professional. And we're one of the only skilled professions who do not get to choose the tools of our trade. If you're a chef, you pick your knives. If you're a general contractor or an architect, you can build you can use whatever you want to use. But as a doctor, as an internist, especially someone who's not a proceduralist that, they don't have operating tools to use, I don't get to choose what I want to use to do my work, and it's a real problem because there becomes a significant misalignment of priorities. So I think that's something that really has to change, but fundamentally, what we're trying to do is get everyone on the same page. 10 years ago, 15 years ago, one person would know everything about a patient, but now we deliver care as a team. So information and knowledge is distributed amongst a lot of people, but our technology is still very designed around one doctor, one nurse, one interaction, and you don't get this whole picture. So that's fundamentally how we're changing the workflow building on top of the EHRs saying, I should say building on top of the investment we've already made in EHRs saying, great, now let's leverage that and say, how do I have a workflow tool that actually helps our delivery, our care delivery teams? Have the information they need when they need it to provide great care.

John Shufeldt:
Was it easy to work with the Cerners and the Epics and Allscripts of the world with, through APIs? How are you getting information in and out of their charts? Because I've heard a couple of them. I think Epic in particular is extremely challenging to work with regarding this information sharing.

Dr. Subha Airan-Javia:
Information blocking is a problem. The Cares Act that just was passed and revised is really focused more on patient, like single patient level information blocking being illegal, not as much patient panel ... level blocking. So it doesn't help for provider-facing applications a lot of times, but is, has a long way to go. Interoperability and standardization, now that as an industry we've accepted FHIR, it's so much easier, at least than it was before, but don't know what the percentage is of organizations that have adopted FHIR over HL7, so it's still pretty challenging. But some organizations are doing a really good job. We just, we did Cerner's API-like Code marketplace program, and it was not easy. It's very regimented because they want to make sure you're doing everything right, but it was super organized, very well done, and now being able to use that to connect to other Cerner sites is exactly as it should be, which is as light a lift on the health system as possible. So I really was very pleasantly surprised with how that experience was. Another really good one was Clarke Care, which is one of the most commonly used in nursing homes. Same thing, so now that we're connected, they're getting turned on is basically someone saying, hey, I want this, and in two weeks, I can get it on. So there is great potential. I don't think all the EHRs have caught up.

John Shufeldt:
Where do you see this business going? What's your exit strategy?

Dr. Subha Airan-Javia:
That's a good question. I'm going to take over the world, John. That's what it is.

John Shufeldt:
Yes, we'll live long and prosper.

Dr. Subha Airan-Javia:
Oh, you know, I'm a Trekkie.

John Shufeldt:
I read that, yeah.

Dr. Subha Airan-Javia:
Yeah, resistance is futile. Yeah, so I see this not being limited to one EHR or one care setting, and that's really one of the big values that people often ask, Do we want to sell to an EHR? I don't, really. I'm happy to work with them and license with them, but one of the key values that we provide is helping bring teams together across all of these different technologies. I see it being much more of a large tech partner or some other health technology partner that is doing a lot of either value-based care initiatives or other technology infrastructure initiatives that is not EHR specific. So that's part of the vision.

John Shufeldt:
As part of the, excellent, very good. This has been totally amazing. Thank you for your time today. This has been really inspiring.

Dr. Subha Airan-Javia:
I appreciate what you're doing because I do think we need more exposure to business and entrepreneurship in medicine. And can I say one more thing real quick?

John Shufeldt:
Oh, yeah, yeah, yeah.

Dr. Subha Airan-Javia:
I have found, and this is advice I would like to give to young clinicians or aspiring clinicians is, we are taught in medicine almost like we need to be martyrs and that anything related to profit or industry is bad. This is so deep-seated, I mean, I feel weird even saying it out loud as if it's not true. And when I went, when I started this company, really felt like I went to the dark side by working for a for-profit endeavor, which, you know, another spoiler alert is you don't make a lot of money in a startup. This is all about having a belief in a mission and doing it because you believe you can improve lives. But I've come to realize that it's really a balance, you can do all sorts of great innovation in one hospital or one university, but it takes industry to be able to take that innovation and spread it to other places. There's just no way. If you think about a vaccine, right, one university might or multiple universities might develop the mRNA vaccine, but it takes industry to be able to take that and distribute it elsewhere. And just as a piece of encouragement to people that this is not a bad thing, it's not the dark side. It's a required part of making something great and getting it into other people's hands.

John Shufeldt:
Yeah, I always say you have to do well to do good, and if you get your business in order, you can do all sorts of good with it. And how you choose to give the profits back to the community or to your shareholders is up to you. But I really agree with you because I think I have a few years on you and I think it was worse when I was doing it because I frankly was one of the ones who said it, you're either in the hospital as a patient, or you're in the hospital seeing patients. None of this I don't feel I'm not coming in ... and because you're right, we all grew up in that world. It's just, profits are bad, it's all about the patient ... things, whatever. And so you're right, but most advances in healthcare come with a profit motive ultimately behind them. And, you know, you don't make a lot, and startups are a total, you know, is it worth it in the end? I think so. But, boy, there's a lot of gray hair and sleepless nights and talking yourself along the way. Oh, yeah. No, I'm with you.

Dr. Subha Airan-Javia:
It's definitely one of the most stressful things I've done in my life.

John Shufeldt:
Yeah, which is saying a lot. You went through undergrad and medical school.

Dr. Subha Airan-Javia:
And residency and treating people in life and death situations and raising human beings. Yes, it is extremely stressful.

John Shufeldt:
Yeah, it's yeah, but it's funny. There's a great quote by Sigmund Freud, I think it's, one day years from now, you'll look back and realize this is the beautiful time. You'll look back and miss this. And I, it happens all the time. Oh, my God. I remember I was driving at 3 a.m. I almost hit this deer in the middle of the reservation. Like, the hell was I doing? But I look back at that now fondly and thinking, God, that was fun. That was really cool. This has been great. Thank you very much.

Dr. Subha Airan-Javia:
Thank you, John. Appreciate you having me.

John Shufeldt:
Thanks. Thanks, everybody. Another wrap, and we'll see you again soon. Thanks.

John Shufeldt:
Thanks for listening to another great edition of Entrepreneur Rx. To find out how to start a business and help secure your future, go to JohnShufeldtMD.com. Thanks for listening.

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