Going from idea to execution: Joshua Landy - Figure 1

0:00 Hi everyone, I'm excited to bring you this conversation with Joshua Landy. Josh is the chief medical officer and co-founder for Frigger One, a social networking and medical education site for doctors. They have raised over $23.5 million in funding and have 3 million users worldwide. He's also practicing intensive care doctor and the medical lead for medical assistance in dying at Scarborough General Hospital here in Ontario. We talk about what it takes to launch your startup from idea to execution. We talk about medical assistance in dying and we also talk about the state of Canadian healthcare. I am grateful for Josh for sharing his frank thoughts and being so transparent and honest with me here. I hope you guys enjoy the conversation as much as I do. Thanks so much Josh for coming on the podcast. I'm really excited for this conversation. If you could start with a brief introduction and then we can get into it.

0:52 Sure, I'd be happy to. Thanks for having me, Rashad. I'm Josh Landy. I'm a practicing intensive care doctor and internal medicine specialist. I practice in Scarborough as well as having a practice up north in Sault Ste. Marie, Ontario. For 10 years, I have been the co-founder of a medical tech company called Frigger One, which is a medical case sharing platform for healthcare professionals so that you can take a picture, write a short caption, and send a case of curiosity, of interest, of teaching to your friends, your colleagues, your teachers, your students, whoever should see it, and they can respond and give you commentary. You can basically learn from the experience of others. Our goal has always been with Frigger One is to democratize the knowledge of medicine, give people access to cases around the world so you can really learn from seeing cases.

1:46 We've been running that company for 10 years. It's now got about 3 million users around the globe in 190 plus countries. I'd be happy to do lots of marketing talk for Frigger One, but I think there's probably more interesting stuff we should talk about. One of the questions our listeners had was, how do you go from idea to execution? Talk me through how you came up with Frigger One, how you recruited your team, did you raise money or not, and how did you launch the product and market? One of the things I think a lot about is how to take ideas from inside your brain and make them exist in the real world. First of all, we drastically underestimate the degree of error in the world. When you consider your ideas and how they work in your mind, you have a model of the world of how it would work. That model does not contain any of the errors. When you are thinking about how a product is going to go, there's no typos in any of the marketing content in your mind. There's no problems with the email server that you now need to spin up a second server because your users are losing out on seeing content or something. All of those things that ruin your enjoyment of things in real life are the difference between theory and reality. You need to leave room and help correct those errors as you go, which means it's always slower than you want.

3:16 That's frustrating for folks like me because I am a super, super impatient person. The first thing I would want, so if a person came to me and said, I have this idea in my brain, it is X, I would say, great, write X down on a piece of paper and then write, what is the step right before X is ready? What is the step before that? See how many you can write down and see how many you know how to do. Then start with the first one, start with the last one on that list, which is the first one you're going to do, and see how far forward you get before you need to add more steps. Really, it's just writing down the recipe for what you're about to make, writing down the outline for the essay you're about to write. It's just thinking it through from beginning to end and making sure you know where to get the pieces. If you're building a physical object, you need to know how do you build one of them? Once you have one, how do you build 10? Once you have 10, how do you build 100?

4:16 The same thing with software. Once you've built it, first of all, building software is not easy, but you also need to know where your users are going to come from. If you're launching a product that you intend to be a business, you don't need 100 users, you need 10,000 or 100,000 or a million users. Each order of magnitude is literally, obviously, it's 10 times bigger than the one before that. These are the hard parts. The idea is not the hard part. The prototype isn't even the hard part. It's taking those prototypes and then giving them to people, getting people to buy into your idea, latch onto your idea, and carry out the process that you've designed for them, and especially for healthcare, because doctors do whatever they want. Not whatever they want, but from a technology perspective, if you're trying to design a process and say, doctors, use this, they're not going to do that. They'll do whatever's best for their workflow because they have practice and they've got patients and they've got an institution within their work. These are all sources of mismatch between your brain and reality. Your job as a founder is to kick all of those things to the side as early as possible and prepare yourself for the battle ahead.

5:31 Perfect. Thanks for that answer, Josh. You said that you're an impatient person. Do you wish you were more patient and how has your impatient helped you and hurt you in your work and personal life? Great question. I give folks a piece of interview advice, which you have just embodied in your question. You know this advice already and it didn't come from me. The advice that I give folks is when they ask you what your strengths and weaknesses are, they're almost always the same thing. Not the same answer, but your strength, like my impatience is my greatest strength and it is also a source of a tremendous amount of weakness.

6:15 You learn to express your skills, your powers, and protect your weaknesses so that you can function, maybe better than others and maybe worse, but at least acceptable to you. Let me see. My impatience definitely is a good thing for ensuring that follow-up gets done early in business. It's really good for deciding that I can do that when it's something that I've never done before and I somehow am able to convince myself that I'm going to try it. For Figure 1, I literally, when we needed to upload the app to the app store, they said we need terms of service.

7:01 My co-founders looked at me and they're like, do you want to take a crack at writing that? I was like, okay. You read a bunch of terms of service and then you copy and paste a little bit, you write from fresh what the parts are that you think are most important, and then instead of, you give it to a lawyer to make sure it's not illegal, and then they give you a check mark, and instead of costing you more money than your company is worth, it costs somebody much less to sort of do a check mark. I'm willing to take things on because I don't feel like I can wait. It's baked into my personality. I was like, this is a kid always rushing to try new things, to test stuff out, to move on with the next step or the next level. I think probably that's why I ended up wanting to be an intensive care specialist. You get immediate feedback if your therapeutic intervention is working. There's no follow-up visits. You don't have to wait.

8:03 Your interactions are short. They're tight. They're focused. Unless my work is super tight and super focused, I will lose focus and just wander away. It sounds like your impatience contributes to you being what they would call scrappy in the startup world, which is a superpower. Talking more about impatience, are your days structured and are you routine-oriented? No. Do you have kids, Josh? How does that work with kids if you're not? Yeah. Right. You know what the weird part is? When I'm on vacation, I design myself a little routine and I will stick to it as close as I can. No, vacation doesn't have a lot of complexity.

8:50 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, have a light breakfast, go to the pool and sit there and read and listen to music, then exercise, then whatever. Throw a nap in there somewhere. I will try to stick to that and do that same day, every day. When I come back, I cannot tolerate routine almost at all. Really? Yeah. It's so difficult for me. I never... This is a fake background. Obviously, I'm sitting in my home office. My desk is cluttered to all hell. I almost never spend time sitting at this desk. In fact, when I want to do serious work, I pack up and I go downtown to a co-workspace where I have a membership. I go there and I pick a different desk than I sat in last time.

9:43 I eat lunch in a weird hour. I think for me, it's just like the novelty is nourishing and anything that feels routine or samey is very grating. I don't know why. With kids, every day is a different struggle. You try to get your kids on a routine. That's the goal, but it never works. It never works. It doesn't help that I've got a kid who's more or less just like me. He doesn't like routine either. Yeah. I'm the same way. I have this internal desire against structure and towards chaos in some ways. To me, there's a deep connection between this preference for chaos or error and the way that we solve problems in the world. It has to do with your error tolerance. It has to do with your ability to correct errors, solve problems, that is. I think we're all driven to seek a different amount of novelty in our day to satisfy our brains. Yeah. I completely agree.

10:52 An increase in entropy is the direction the universe is going in. There's no point in finding it. Let's talk about failure. It's easy to talk about failure from the past. I'll ask you a more difficult question. What's something you're failing at right now? Something I'm failing at right now is trying to figure out an exit plan out of clinical medicine into a solopreneur. I've been trying for a few months and I've made $0 in my solopreneur journey so far. What is something you're failing at right now, Josh? I was supposed to start a venture with two friends this summer. I am looking at the prototype on my desk. This is my project to move forward and it's still something on my desk. The label says that the company started in December, but I'm looking at the clock and we have 11 days left. This company is not launching in December. This company didn't launch in November. It didn't launch in October. It didn't launch in September. A specific failure would just be like, I'm management and maybe just my expectations of how long things were going to take. I'll push back on that a little bit, Josh. Adam Grant, he's a professor at Wharton MBA school and he talks about success quite a bit. In his book Originals, he says the path to maximize success is moderate procrastination, which is what I think you're doing. You let ideas incubate and you don't

12:27 act right away. Yeah, I like that. I like that. You get to chew on stuff for a while and then you get to reread the copy that you wrote two weeks ago and be like, no, I can make it a little better. I can optimize it. It gives you lots of chances for further optimizations. I think I probably entrepreneur the same way that I cook, which is start for things that need way more management than you have time for and then just basically walk in circles in the kitchen, like sealing this, stirring that, checking on this, turning that and you just keep going until you have food arriving as being ready to be plated. Yeah, and just to tie it up, the way he figured out moderate procrastination was he looked at which students got the best grades, the ones who submitted the earliest, the ones who did it last minute, or the ones who wrote it earlier. So, he was early, but waited until they submitted it and it was the ones who wrote their papers early and just kept working on it till the last second and submitted the last second. Josh, what is the failure you're grateful for and what is one you regret the most? I mean, there's lots of ones in the past that's sort of like very grateful for the path that I was set on.

13:47 So, when I finished my clinical training, I wanted to do research on medical education at the University of Toronto and maybe even pursue graduate studies. Nobody was interested in supervising me. That did not feel good, right? That felt like a failure. And then like the correction turned out to be that I had this like the time and space to go to Stanford and meet people and basically invited myself to research with a group who then subsequently invited me to be a visiting scholar with their team, write papers. And when I finished that, I came back to Toronto and started figure one off of the back of the research that was done as a result of not being able to do the thing I had initially wanted to do. It sounds like that was a failure that you didn't know you needed. Yeah. I mean, it was a failure at something that I probably wouldn't have been really well fit for. Right? So, like, did I fail or did I accidentally succeed? Right? Like in retrospect, you can't really say.

14:57 Let's talk about our healthcare system. Okay. In our current healthcare system, the organizations which pay us, the ones that guide our standard of care and providers with a license are separate. So, the CPSO is separate from the Ministry of Health, which is both good and bad. In some ways, it creates some separation from unfair work conditions, but in other ways, it dictates the CPSO to say, you need to provide this level of care. And then the Ministry of Health to say, okay, you'll only be paid $15 for it. When I say $15, which is a new phone consult fee. Is that separation justified, you feel? And would a singular organization that is be more accountable to the public if it were to both guide our standard and our pay? Wow. That's a rich question. There's a lot in there.

16:01 And I think I probably can just give you one take, which isn't even really an answer, but I think that the tension between the purse string holder and the practice creator is probably a, I think it's a beneficial one, even if it's more tension or more friction than we want. We would prefer that the physician side have more leverage over the government in that situation. And I'm sure that in many budget meetings, the government cannot understand why there is so much leverage already held by the physicians and for them to earn the salaries that they do, that we do on the physicians. So I think it's important to separate those things because even though physicians are a good group to have as self-regulated, I think there's like tremendous potential for trouble with self-regulation. This is like another piece of like my Popperian preference, but Karl Popper, who was famous philosopher of science and political science, adapted the long-standing question of how do you choose your leaders? And so that question in philosophy is generally called who should rule? And should it be a family whose family culture is understanding the nature of leadership like a monarchy? Should it be a democracy? Should it be

17:34 fascist totalitarian? Popper said that's the wrong question. Don't say who should rule. Ask the question how do we peacefully remove a problematic ruler? That is the question to ask because then it does not matter who is ruling. There is a process that will dump bad rulers and install the next one and if they're bad too, they'll go out and you keep doing it till you get a good one. And then when that one's no good, you get the next one. And the idea is you need to be able to change the leadership more than you need to be able to control the leadership.

18:15 Yeah, I think that opens up the debate to if AI could lead us, could judge us, should be allowed to and do we want the world to be fair? Because our sense of fairness is not fair generally. It's unfair to a vast majority of people and it exists within our world. It exists within our microcosm of fairness and unfairness and ethics. AI is not really creating a lot of stuff, right? It's representing things we have said and done in the past. AI leading anything like that would be unsuccessful for that reason, that it would be regressive and not progressive. If you could change one thing in healthcare, what would it be, Josh? I would want hospitals to control the employment of the physicians that work there. I think hospitals should be able to fire doctors. Interesting. I'm assuming there's a story behind this. No, I just like the story is that there's a hundred stories of me seeing people, like doing jobs that you wouldn't let them do if this was a company and they worked for the company.

19:31 People going off book, doing individualized care that is not evidence-based. Everyone knows a few physicians who don't answer their pager. Everyone knows that this person will not do surgery on a Friday night, no matter what, but they're still on call on Friday night. So the patients just wait into the morning. We all know people who have put the dilator into a chest instead of the actual chest tube. No, we don't all know people like that, but we all know examples where somebody just did something completely unbelievable because they had a low level of skill and it just wasn't noticed, caught or cared about. And then the person's on staff and it can't be fired because of Ontario's, just like the precedents that are in the court for like what you're allowed to do and who's allowed to control physicians. But if you're allowed to say that we expect physicians to practice in this way and you'll lose your privileges or your job, I think there would be a lot more compliance. And unfortunately, hospitals get stuck with people practicing sometimes way too late, not changing their practice for the last 15 years of their own practice.

20:42 And you get heterogeneous care that you can't measure where the errors are coming from. But it's from the people who are not doing what the college expects them to, but they're not doing such a bad job that they get reported. Where do you see the future of Canadian healthcare going in terms of privatization? Private healthcare has existed in Canada for decades in the realm of the Homewoods, MedCas, Cleveland Clinics, Maple Dialogue for a couple of newer ones. But there seems to be an identity crisis that free healthcare is more important than access to healthcare. And I'm not saying private or public healthcare will provide more access, but our current system is, from my perspective, doing a terrible job of providing access to care. Part of that might be because physicians are independent, we are free to work as we please to an extent.

21:45 Where do you see the future of private healthcare? Do you see private healthcare expanding care and access, or do you see it limiting care? The free market will subsume the space that it occupies. And so as long as you have a border between what is free and what is not, things will continue to expand in the what is not free territory. And once the border is moved, that space will get consumed or subsumed as well. So you sort of picture like a diagram where there's a smaller circle labeled free healthcare, and there's a larger circle outside that labeled for-profit healthcare.

22:31 Like that for-profit space is just going to be packed. So I don't know where our care system is going to go in the future, but I think there'll be probably services that need increased access will become more privatizable, and services that remain core and expensive and difficult to decentralize will remain public. Yeah, the worry I have is the opposite will happen, and services like surgeries and chemotherapy will become private. And services like primary care, which is where I think should be more private, will stay public. I think to increase access to primary care, we need a direct primary care model in Canada where physicians can charge subscription. And you can cap that subscription to $50 a month or something reasonable. I think that is the best way, but the worry is it will be more ambulatory surgery centers and almost many EDs and urgent care centers where the private money will flow. I love the idea of decentralized healthcare with basically like disillusion of a lot of secondary care type hospitals where that care is now deferred to people's homes. You think about what the Amazon for healthcare or what the Uber for healthcare is going to be. And you can

24:01 see that somebody might wake up with shortness of breath and a cough, and then a respiratory assessment arrives at their door and they swab themselves, and somebody comes and collects their blood. The oxygen company comes and drops off a tank. The portable x-ray company comes by and takes that person's x-ray and a nurse checks in by video two or three times a day, reading the vitals from the telemetry that is in the kit. It's easy to imagine. We have this technology. If we wanted to fake build it today, we could. And I'm excited for that future. Let's talk about medical assistance and dying. For those who don't know, I used to provide medical assistance in dying. I've helped nine patients. And the reason I stopped is emotionally, it was very rewarding, but very taxing. And usually, it took me a day and a half for the whole procedure and the consults. And this may sound unfortunate, but it just wasn't financially, and there weren't enough financial incentives for me to continue.

25:08 Let's talk about advanced directive for made. I didn't mention it in my intro, but I'm the made clinical lead for Scarborough's SHN. So that's why we're talking about this. Let's talk about your thoughts on advanced directive for made. And if you could tell me what a good death for you looks like, in my experience, there's tension between alleviating pain and suffering and maximizing alertness and awareness as some patients desire. A good death for me is when I decide where and when I go. I'm 80 and I get a diagnosis of whatever year to live.

25:51 And I'm like, okay, this is it for me. And I am in control till the very end. And I maintain my autonomy. So tell me what a good death for you looks like and your thoughts on advanced directives for made. So I probably agree a lot with you about the good death scenario. I mean, I think a lot of it's about autonomy, control, comfort, and reduction of anxiety. The thing that as an intensive care physician, I palliate a small proportion of my patients and seeing and understanding what their needs are has really shaped how I've entered my made cases. And so making sure that I can assure the patient and their family that you will pass without pain, without anxiety, and without thinking about that process happening to you. But what is it that you want? You want your pain to be gone or your suffering to be removed. You want to not be thinking about it. So while it may not be a death that everybody would choose for themselves, I think there are many good deaths. And I think we've had at Scarborough, almost all of them have been that way. To talk about advanced directives, there's a concept called the transformative experience, which I think intuitively is the same as it is in the technical term. Except technically, the most important thing to remember is that you cannot predict what and how you will feel following your transformative experience.

27:24 It is not knowable from your previous state. That's sort of the important thing. It's sort of like a one way, it's a one way membrane, it's an event horizon, whatever you want to call it. And I think that dementia is probably one of those things. And so I worry about advanced directives because I am not confident that the person who is sitting in front of me with a pleased but glazed look in their eyes is suffering in the same way that that physically same person expected themselves to be suffering when they compose that document of sound mind. You said it beautifully. Your self now is so vastly distinct from yourself if you have dementia.

28:11 You cannot make any parallels and any decisions for your dementia self by putting yourself in that picture. This is an impossible decision because we say once you have dementia, you don't have decision making capacity. And we generally are against, and I think for good reason, for others to make decisions for us on our behalf. Thanks so much for coming on. This was a very engaging and informative conversation for me. I hope you had fun as well. We'll have to do more of this at some point and talk a bit more about life and purpose.

28:51 Yeah, I'd love to do that. Let's get down to the bottom of that and we can let everyone know. Thanks, Josh. Okay, thanks for sharing.