Going from idea to execution: Joshua Landy - Figure 1

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Hi everyone, I'm excited to bring you this conversation with Joshua Landy. Josh is the

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chief medical officer and co-founder for Frigger One, a social networking and medical education

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site for doctors. They have raised over $23.5 million in funding and have 3 million users

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worldwide. He's also practicing intensive care doctor and the medical lead for medical

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assistance in dying at Scarborough General Hospital here in Ontario. We talk about what it takes

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to launch your startup from idea to execution. We talk about medical assistance in dying and we

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also talk about the state of Canadian healthcare. I am grateful for Josh for sharing his frank

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thoughts and being so transparent and honest with me here. I hope you guys enjoy the conversation

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as much as I do. Thanks so much Josh for coming on the podcast. I'm really excited for this

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conversation. If you could start with a brief introduction and then we can get into it.

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Sure, I'd be happy to. Thanks for having me, Rashad. I'm Josh Landy. I'm a practicing intensive care

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doctor and internal medicine specialist. I practice in Scarborough as well as having a practice up

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north in Sault Ste. Marie, Ontario. For 10 years, I have been the co-founder of a medical tech company

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called Frigger One, which is a medical case sharing platform for healthcare professionals

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so that you can take a picture, write a short caption, and send a case of curiosity, of interest,

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of teaching to your friends, your colleagues, your teachers, your students, whoever should see it,

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and they can respond and give you commentary. You can basically learn from the experience

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of others. Our goal has always been with Frigger One is to democratize the knowledge of medicine,

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give people access to cases around the world so you can really learn from seeing cases.

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We've been running that company for 10 years. It's now got about 3 million users around the globe

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in 190 plus countries. I'd be happy to do lots of marketing talk for Frigger One, but I think

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there's probably more interesting stuff we should talk about. One of the questions our listeners had

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was, how do you go from idea to execution? Talk me through how you came up with Frigger One,

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how you recruited your team, did you raise money or not, and how did you launch the product and market?

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One of the things I think a lot about is how to take ideas from inside your brain

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and make them exist in the real world. First of all, we drastically underestimate the degree of

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error in the world. When you consider your ideas and how they work in your mind, you have a model

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of the world of how it would work. That model does not contain any of the errors. When you are

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thinking about how a product is going to go, there's no typos in any of the marketing content in your

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mind. There's no problems with the email server that you now need to spin up a second server

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because your users are losing out on seeing content or something. All of those things that

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ruin your enjoyment of things in real life are the difference between theory and reality. You need to

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leave room and help correct those errors as you go, which means it's always slower than you want.

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That's frustrating for folks like me because I am a super, super impatient person. The first thing I

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would want, so if a person came to me and said, I have this idea in my brain, it is X, I would say,

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great, write X down on a piece of paper and then write, what is the step right before X is ready?

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What is the step before that? See how many you can write down and see how many you know how to do.

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Then start with the first one, start with the last one on that list, which is the first one you're

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going to do, and see how far forward you get before you need to add more steps. Really, it's just

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writing down the recipe for what you're about to make, writing down the outline for the essay

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you're about to write. It's just thinking it through from beginning to end and making sure you

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know where to get the pieces. If you're building a physical object, you need to know how do you

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build one of them? Once you have one, how do you build 10? Once you have 10, how do you build 100?

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The same thing with software. Once you've built it, first of all, building software is not easy,

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but you also need to know where your users are going to come from. If you're launching a product

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that you intend to be a business, you don't need 100 users, you need 10,000 or 100,000 or a million

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users. Each order of magnitude is literally, obviously, it's 10 times bigger than the one

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before that. These are the hard parts. The idea is not the hard part. The prototype isn't even the

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hard part. It's taking those prototypes and then giving them to people, getting people to buy into

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your idea, latch onto your idea, and carry out the process that you've designed for them,

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and especially for healthcare, because doctors do whatever they want. Not whatever they want, but

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from a technology perspective, if you're trying to design a process and say, doctors, use this,

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they're not going to do that. They'll do whatever's best for their workflow because they have

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practice and they've got patients and they've got an institution within their work. These are all

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sources of mismatch between your brain and reality. Your job as a founder is to kick all of those

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things to the side as early as possible and prepare yourself for the battle ahead.

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Perfect. Thanks for that answer, Josh. You said that you're an impatient person.

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Do you wish you were more patient and how has your impatient helped you and hurt you

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in your work and personal life? Great question. I give folks a piece of interview advice, which

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you have just embodied in your question. You know this advice already and it didn't come from me.

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The advice that I give folks is when they ask you what your strengths and weaknesses are,

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they're almost always the same thing. Not the same answer, but your strength, like my impatience

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is my greatest strength and it is also a source of a tremendous amount of weakness.

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You learn to express your skills, your powers, and protect your weaknesses

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so that you can function, maybe better than others and maybe worse, but at least acceptable to you.

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Let me see. My impatience definitely is a good thing for ensuring that follow-up gets done early

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in business. It's really good for deciding that I can do that when it's something that I've never

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done before and I somehow am able to convince myself that I'm going to try it. For Figure 1,

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I literally, when we needed to upload the app to the app store, they said we need terms of service.

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My co-founders looked at me and they're like, do you want to take a crack at writing that?

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I was like, okay. You read a bunch of terms of service and then you copy and paste a little bit,

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you write from fresh what the parts are that you think are most important, and then instead of,

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you give it to a lawyer to make sure it's not illegal, and then they give you a check mark,

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and instead of costing you more money than your company is worth, it costs somebody much less to

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sort of do a check mark. I'm willing to take things on because I don't feel like I can wait.

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It's baked into my personality. I was like, this is a kid always rushing to try new things,

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to test stuff out, to move on with the next step or the next level. I think probably that's why

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I ended up wanting to be an intensive care specialist. You get immediate feedback if your

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therapeutic intervention is working. There's no follow-up visits. You don't have to wait.

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Your interactions are short. They're tight. They're focused. Unless my work is super tight

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and super focused, I will lose focus and just wander away. It sounds like your impatience

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contributes to you being what they would call scrappy in the startup world, which is a superpower.

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Talking more about impatience, are your days structured and are you routine-oriented?

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No. Do you have kids, Josh? How does that work with kids if you're not?

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Yeah. Right. You know what the weird part is? When I'm on vacation, I design myself a little

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routine and I will stick to it as close as I can. No, vacation doesn't have a lot of complexity.

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If I get to spend time at a resort or at a hotel with a pool, it'll be like, wake up at this time,

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have a light breakfast, go to the pool and sit there and read and listen to music, then exercise,

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then whatever. Throw a nap in there somewhere. I will try to stick to that and do that same day,

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every day. When I come back, I cannot tolerate routine almost at all.

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Really? Yeah. It's so difficult for me. I never... This is a fake background. Obviously,

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I'm sitting in my home office. My desk is cluttered to all hell. I almost never spend time sitting at

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this desk. In fact, when I want to do serious work, I pack up and I go downtown to a co-workspace

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where I have a membership. I go there and I pick a different desk than I sat in last time.

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I eat lunch in a weird hour. I think for me, it's just like the novelty is nourishing and anything

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that feels routine or samey is very grating. I don't know why. With kids, every day is a different

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struggle. You try to get your kids on a routine. That's the goal, but it never works. It never

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works. It doesn't help that I've got a kid who's more or less just like me. He doesn't like routine

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either. Yeah. I'm the same way. I have this internal desire against structure and towards chaos

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in some ways. To me, there's a deep connection between this preference for chaos or error and

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the way that we solve problems in the world. It has to do with your error tolerance. It has to do

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with your ability to correct errors, solve problems, that is. I think we're all driven

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to seek a different amount of novelty in our day to satisfy our brains. Yeah. I completely agree.

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An increase in entropy is the direction the universe is going in. There's no point in finding

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it. Let's talk about failure. It's easy to talk about failure from the past. I'll ask you a more

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difficult question. What's something you're failing at right now? Something I'm failing at right now is

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trying to figure out an exit plan out of clinical medicine into a solopreneur. I've been trying for

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a few months and I've made $0 in my solopreneur journey so far. What is something you're failing

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at right now, Josh? I was supposed to start a venture with two friends this summer. I am

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looking at the prototype on my desk. This is my project to move forward and it's still something

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on my desk. The label says that the company started in December, but I'm looking at the

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clock and we have 11 days left. This company is not launching in December. This company didn't

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launch in November. It didn't launch in October. It didn't launch in September. A specific failure

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would just be like, I'm management and maybe just my expectations of how long things were going to

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take. I'll push back on that a little bit, Josh. Adam Grant, he's a professor at Wharton MBA school

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and he talks about success quite a bit. In his book Originals, he says the path to maximize success

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is moderate procrastination, which is what I think you're doing. You let ideas incubate and you don't

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act right away. Yeah, I like that. I like that. You get to chew on stuff for a while and then

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you get to reread the copy that you wrote two weeks ago and be like, no, I can make it a little

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better. I can optimize it. It gives you lots of chances for further optimizations. I think I

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probably entrepreneur the same way that I cook, which is start for things that need way more

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management than you have time for and then just basically walk in circles in the kitchen,

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like sealing this, stirring that, checking on this, turning that and you just keep going until you have

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food arriving as being ready to be plated. Yeah, and just to tie it up, the way he figured out

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moderate procrastination was he looked at which students got the best grades, the ones who submitted

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the earliest, the ones who did it last minute, or the ones who wrote it earlier. So, he was

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early, but waited until they submitted it and it was the ones who wrote their papers early and just

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kept working on it till the last second and submitted the last second. Josh, what is the

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failure you're grateful for and what is one you regret the most? I mean, there's lots of

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ones in the past that's sort of like very grateful for the path that I was set on.

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So, when I finished my clinical training, I wanted to do research on medical education

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at the University of Toronto and maybe even pursue graduate studies. Nobody was interested

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in supervising me. That did not feel good, right? That felt like a failure. And then like

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the correction turned out to be that I had this like the time and space to go to Stanford

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and meet people and basically invited myself to research with a group who then subsequently

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invited me to be a visiting scholar with their team, write papers. And when I finished that,

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I came back to Toronto and started figure one off of the back of the research that was done

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as a result of not being able to do the thing I had initially wanted to do. It sounds like that

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was a failure that you didn't know you needed. Yeah. I mean, it was a failure at something that

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I probably wouldn't have been really well fit for. Right? So, like, did I fail or did I

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accidentally succeed? Right? Like in retrospect, you can't really say.

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Let's talk about our healthcare system. Okay. In our current healthcare system,

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the organizations which pay us, the ones that guide our standard of care and providers with

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a license are separate. So, the CPSO is separate from the Ministry of Health,

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which is both good and bad. In some ways, it creates some separation from unfair work conditions,

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but in other ways, it dictates the CPSO to say, you need to provide this level of care.

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And then the Ministry of Health to say, okay, you'll only be paid $15 for it. When I say $15,

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which is a new phone consult fee. Is that separation justified, you feel? And would

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a singular organization that is be more accountable to the public if it were to

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both guide our standard and our pay? Wow. That's a rich question. There's a lot in there.

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And I think I probably can just give you one take, which isn't even really an answer,

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but I think that the tension between the purse string holder and the practice creator is probably

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a, I think it's a beneficial one, even if it's more tension or more friction than we want.

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We would prefer that the physician side have more leverage over the government in that situation.

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And I'm sure that in many budget meetings, the government cannot understand why there is so much

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leverage already held by the physicians and for them to earn the salaries that they do,

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that we do on the physicians. So I think it's important to separate those things because

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even though physicians are a good group to have as self-regulated, I think there's like tremendous

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potential for trouble with self-regulation. This is like another piece of like my

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Popperian preference, but Karl Popper, who was famous philosopher of science and political science,

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adapted the long-standing question of how do you choose your leaders? And so that question

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in philosophy is generally called who should rule? And should it be a family whose family culture is

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understanding the nature of leadership like a monarchy? Should it be a democracy? Should it be

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fascist totalitarian? Popper said that's the wrong question. Don't say who should rule. Ask the question

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how do we peacefully remove a problematic ruler? That is the question to ask because then it

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does not matter who is ruling. There is a process that will dump bad rulers and install the next one

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and if they're bad too, they'll go out and you keep doing it till you get a good one.

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And then when that one's no good, you get the next one. And the idea is you need to be able to

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change the leadership more than you need to be able to control the leadership.

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Yeah, I think that opens up the debate to if AI could lead us, could judge us,

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should be allowed to and do we want the world to be fair? Because our sense of fairness is

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not fair generally. It's unfair to a vast majority of people and it exists within our world.

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It exists within our microcosm of fairness and unfairness and ethics.

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AI is not really creating a lot of stuff, right? It's representing things we have said and done

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in the past. AI leading anything like that would be unsuccessful for that reason, that it would

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be regressive and not progressive. If you could change one thing in healthcare,

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what would it be, Josh? I would want hospitals to control the employment of the physicians that work

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there. I think hospitals should be able to fire doctors. Interesting. I'm assuming there's a story

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behind this. No, I just like the story is that there's a hundred stories of me seeing people,

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like doing jobs that you wouldn't let them do if this was a company and they worked for the company.

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People going off book, doing individualized care that is not evidence-based. Everyone knows a few

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physicians who don't answer their pager. Everyone knows that this person will not do surgery on a

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Friday night, no matter what, but they're still on call on Friday night. So the patients just wait

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into the morning. We all know people who have put the dilator into a chest instead of the actual

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chest tube. No, we don't all know people like that, but we all know examples where somebody

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just did something completely unbelievable because they had a low level of skill and it just wasn't

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noticed, caught or cared about. And then the person's on staff and it can't be fired because of

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Ontario's, just like the precedents that are in the court for like what you're allowed to do and

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who's allowed to control physicians. But if you're allowed to say that we expect physicians to

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practice in this way and you'll lose your privileges or your job, I think there would be a lot more

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compliance. And unfortunately, hospitals get stuck with people practicing sometimes way too late,

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not changing their practice for the last 15 years of their own practice.

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And you get heterogeneous care that you can't measure where the errors are coming from.

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But it's from the people who are not doing what the college expects them to, but they're not doing

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such a bad job that they get reported. Where do you see the future of Canadian healthcare going

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in terms of privatization? Private healthcare has existed in Canada for decades in the realm of

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the Homewoods, MedCas, Cleveland Clinics, Maple Dialogue for a couple of newer ones.

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But there seems to be an identity crisis that free healthcare is more important than access to

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healthcare. And I'm not saying private or public healthcare will provide more access, but our

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current system is, from my perspective, doing a terrible job of providing access to care. Part of

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that might be because physicians are independent, we are free to work as we please to an extent.

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Where do you see the future of private healthcare? Do you see

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private healthcare expanding care and access, or do you see it limiting care?

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The free market will subsume the space that it occupies. And so as long as you have

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a border between what is free and what is not, things will continue to expand in the what is not

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free territory. And once the border is moved, that space will get consumed or subsumed as well.

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So you sort of picture like a diagram where there's a smaller circle labeled

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free healthcare, and there's a larger circle outside that labeled for-profit healthcare.

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Like that for-profit space is just going to be packed. So I don't know where our

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care system is going to go in the future, but I think there'll be probably services that need

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increased access will become more privatizable, and services that remain core and expensive

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and difficult to decentralize will remain public.

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Yeah, the worry I have is the opposite will happen, and services like surgeries and chemotherapy

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will become private. And services like primary care, which is where I think should be more private,

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will stay public. I think to increase access to primary care, we need a direct primary care

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model in Canada where physicians can charge subscription. And you can cap that subscription

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to $50 a month or something reasonable. I think that is the best way, but the worry is it will

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be more ambulatory surgery centers and almost many EDs and urgent care centers where the private

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money will flow. I love the idea of decentralized healthcare with basically like disillusion of a

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lot of secondary care type hospitals where that care is now deferred to people's homes. You think

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about what the Amazon for healthcare or what the Uber for healthcare is going to be. And you can

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see that somebody might wake up with shortness of breath and a cough, and then a respiratory

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assessment arrives at their door and they swab themselves, and somebody comes and collects their

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blood. The oxygen company comes and drops off a tank. The portable x-ray company comes by and

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takes that person's x-ray and a nurse checks in by video two or three times a day, reading the

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vitals from the telemetry that is in the kit. It's easy to imagine. We have this technology.

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If we wanted to fake build it today, we could. And I'm excited for that future.

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Let's talk about medical assistance and dying. For those who don't know, I used to provide medical

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assistance in dying. I've helped nine patients. And the reason I stopped is emotionally,

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it was very rewarding, but very taxing. And usually, it took me a day and a half for the whole

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procedure and the consults. And this may sound unfortunate, but it just wasn't

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financially, and there weren't enough financial incentives for me to continue.

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Let's talk about advanced directive for made.

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I didn't mention it in my intro, but I'm the made clinical lead for Scarborough's SHN.

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So that's why we're talking about this.

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Let's talk about your thoughts on advanced directive for made. And if you could tell me

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what a good death for you looks like, in my experience, there's tension between alleviating

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pain and suffering and maximizing alertness and awareness as some patients desire. A good death

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for me is when I decide where and when I go. I'm 80 and I get a diagnosis of whatever year to live.

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And I'm like, okay, this is it for me. And I am in control till the very end. And I maintain my

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autonomy. So tell me what a good death for you looks like and your thoughts on advanced directives

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for made. So I probably agree a lot with you about the good death scenario. I mean, I think a lot of

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it's about autonomy, control, comfort, and reduction of anxiety. The thing that as an

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intensive care physician, I palliate a small proportion of my patients and seeing and understanding

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what their needs are has really shaped how I've entered my made cases. And so making sure that I

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can assure the patient and their family that you will pass without pain, without anxiety, and without

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thinking about that process happening to you. But what is it that you want? You want your pain to be

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gone or your suffering to be removed. You want to not be thinking about it. So while it may not be

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a death that everybody would choose for themselves, I think there are many good deaths. And I think

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we've had at Scarborough, almost all of them have been that way. To talk about advanced directives,

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there's a concept called the transformative experience, which I think intuitively is the

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same as it is in the technical term. Except technically, the most important thing to remember

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is that you cannot predict what and how you will feel following your transformative experience.

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It is not knowable from your previous state. That's sort of the important thing. It's sort of like a

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one way, it's a one way membrane, it's an event horizon, whatever you want to call it. And I think

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that dementia is probably one of those things. And so I worry about advanced directives because

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I am not confident that the person who is sitting in front of me with a pleased but glazed look in

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their eyes is suffering in the same way that that physically same person expected themselves to be

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suffering when they compose that document of sound mind.

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You said it beautifully. Your self now is so vastly distinct from yourself if you have dementia.

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You cannot make any parallels and any decisions for your dementia self by putting yourself in that

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picture. This is an impossible decision because we say once you have dementia, you don't have

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decision making capacity. And we generally are against, and I think for good reason, for others

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to make decisions for us on our behalf. Thanks so much for coming on. This was a very engaging and

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informative conversation for me. I hope you had fun as well. We'll have to do more of this

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at some point and talk a bit more about life and purpose.

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Yeah, I'd love to do that. Let's get down to the bottom of that and we can let everyone know.

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Thanks, Josh.

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Okay, thanks for sharing.