What is a good death? Raihan Faroqui

0:00 Hi, Rayhan. Thanks for joining me today. I've been looking forward to this quite a bit. I know we've been talking for the past few months. If you can start with a brief introduction and then we'll get right into it. Yeah, thanks so much for shot for having me on. My name is Dr. Rayhan Farooqi. I am a NYC based health tech startup entrepreneur with expertise as an operator, advisor and consultant. I've worked in healthcare and health tech for the last eight years. And by training, I am an internal medicine physician. I am now non-practicing and I'm also a published neurology researcher.

0:41 As a startup operator, I currently serve as head of medical affairs at Guaranteed. We are a VC backed startup. We've raised about $10 million total in the last year, both a pre-seed and a seed round. And we are scaling tech enabled in-home hospice care delivery, modernizing the end of life care experience. Perfect. Thanks for that introduction. I think let's start with your childhood and talk me through about school. Were you good at school? What did you want to be when you were five, when you were 10, when you were 15 and your paths to medical school and residency?

1:23 Yeah, leave it to a brown guy to talk to me about my childhood. So I have spent most of my life in New York. I was born and raised in Rockland County, really nice NYC commuter suburbs. I come from a healthcare family. My father is now a retired respiratory care provider. I have cousins who are physicians, dentists, pharmacists, nurses, therapists, and everything that you can think. My mother is a childcare provider. She's a businesswoman. I learned a lot from her in terms of hard work and kind of ethical behavior.

2:13 I had a very traditional childhood as a son of immigrants. We grew up working class. Both my parents worked really hard. My dad, growing up, he pumped gas during the day. He went to school at night. And my mom took care of other family's kids, kind of un-glorified workers. I think that taught me a lot about the value of hard work and your very typical South Asian immigrant parents' dreams that we're going to work really hard, but we want to provide you with the best education, the best resources as possible.

3:04 So I kind of grew up with that environment. My parents immigrated from Bangladesh and settled in this area. I went to some great public schools in Rockland County. I graduated from a top ranked high school in the state. I was super nerdy growing up. I took all of the difficult classes and courses. I come home from school, do homework. It was just really prized for me to be a top student. And it's something that I relished. I enjoyed being an academic even from that age.

3:48 Some of my fondest memories include my mother taking me to the library, checking out every book that I could get my hands on, reading voraciously from a young age. But having a really wonderful childhood, I have two amazing younger sisters. Sure, we had our battles when we were younger, and they both work in healthcare. Now one is a speech language pathologist and one is an occupational therapist. So yeah, I think growing up, it was expected for all of us to do really well academically. And healthcare was always, I think, in the cards for some of us, because of my dad's job as a respiratory therapist. And my mom's dreams of having us work in healthcare and providing for other people, helping people out.

4:41 And I think for me personally being part of a kind of close knit spiritual community, I grew up going to the mosque, kind of going there every week, kind of listening to our teachers speak about the value of service, of kind of salvation, really being rooted in selflessness, you know, helping others actually helps yourself. And that's really the purpose of life. So I think at a very young age, you know, family, faith, personal motivation, I knew I wanted to help others and kind of clinical medicine was one very tangible pathway of doing that.

5:26 Okay, perfect. So you do all this hard work, you get straight A's, like any good Brown kid. You know, growing up the options for me were doctor or doctor, and I chose doctor. Oh, great. So you were not given the wonderful options of engineer or lawyer. Great. I was not. It's a story for another day. You find yourself in residency and you worked very hard to get here. Yeah, gone through struggles, I imagine. And shortly after your residency into the world of entrepreneurship. Yeah, talk me through that journey that decision, what brought on that transition? And what factors? Yeah, do you feel there are certain personalities that do well in medicine? And how does that transfer over to entrepreneurship?

6:17 For me, it was a messy journey, if I will be radically honest with you, I had a vision for myself as someone who had multiple academic and professional interests. And as an undergrad student, I went to Cornell, in many ways, a very toxic environment. Lots of high achieving folks who were double and triple majoring depression, drug use was rampant on campus. And it was hard. You know, I think having imposter syndrome. Do I belong? Am I going to make it? Is real.

6:58 Having a sense of loss, not knowing if I'm going to make it was transparent. I think at the same time, I, you know, minored in international relations. I've always had an interest in politics and political campaigns. Lots of my friends know that. I also had a real interest in terms of business and entrepreneurship. I was very different compared to a lot of my friends who were premed, who were biology, research, volunteering, just heads down and I was I was very different.

7:38 And I surrounded myself with folks who now work in tech and consulting and finance, they got jobs at Goldman Sachs and Google and my premed friends that didn't hang around with kids like that, but I did. And many of those folks are my closest friends now. And I think that like surrounding myself with peers who were very different academically and had different passions had a lasting impact on me. But I think at that time, especially as an undergrad, I realized that, Hey, look, I do want to practice as a fitness physician, but I also want to do other things in my life. And that to me was indicative of there's another chapter that will be written and I didn't know how or what form that would take. And if you kind of fast forward to medical school, I was actively searching for health tech startups to work with to work for.

8:36 But the seeds really were planted much earlier. And when I was an undergrad, I took a entrepreneurship class in our business school with first year MBAs, me and two friends. We kind of entered a kind of pitch competition and our idea, which was halal frozen foods, ended up winning the competition. And I remember the professor at the time saying, Hey, you guys should, like really work on this. And I'm like, I'm going to go to med school, like I'm not launching a launching a business right now. But, but I knew at that at that stage still like that bug was not going to go away.

9:23 At the same time, I knew I had to supplement my education with learnings from other industries, whether that was business, engineering or tech, and I knew that was going to be important in my journey. Okay, perfect. Thanks for sharing that, Rayhan. Talking about imposter syndrome, I think it's a sign of self reflection and introspection. How do you define success? And the way I want you to think about this question is imagine your five year old coming to you and asking you, Dad, what is success? How do I know I'm successful?

10:03 Would you tell him or her? Yeah, I think about this a lot. I think, you know, success is understanding being who you think you are. What I mean by that is, I think kind of self actualization is really important in the journey of life. When you're younger, as you're figuring out your identity and your purpose, you oftentimes tell a story of yourself to yourself. That's not true. And a lot of people do that, not because you're being manipulative, or you have ill intention, you're lost, or you're confused. On the flip side, you're in the process of exploration and self discovery.

10:59 And I think when I was young, I told a story of myself to myself that was not true. And what I've really felt is that when you take that story of yourself that is not true, and then you tell that to other people, there's a fundamental misalignment, and that results in stress, confusion, a real lack of purpose in your life. And I felt that I've succeeded, because in the last few years, as a lot of my kind of messiness in terms of like, who am I as a person? What is my purpose in terms of my career and profession? What is my impact? How do I serve people?

11:40 There has been a fundamental alignment of that story. So that story that I tell to myself, and that story that I tell of myself to others is now one. And that to me is ultimate success, where I feel a lot of gratitude. I feel a deep sense of purpose. I wake up incredibly energized, because there is that alignment. Okay, perfect. Let's dig a bit deeper. What was the story you told yourself before? And what's the story you tell yourself now? That's a great question. I used to tell a future story of myself. I would say I'm a doctorpreneur, but it wasn't necessarily true. And I know you and I have talked very candidly about failure. And I graduate from an Ivy League school.

12:37 I think I'm hot, four letter word. I'm not sure if I can curse here. And I wasn't. I had a lot of elitism. I was pretentious. I think when I look back, I actually was not proud of the person that I was at the time. And I think a lot of my behavior was probably not cool. And I struggled academically. I got lots of B's and C's, and my report card was not great. And I actually did not get into a US medical school, which for me was humiliating. But at the same time, it was, I think, a necessary.

13:21 It was a necessary lesson in humility. And looking back in hindsight is the best thing that ever happened to me. You know, it made me really hungry. It proved to me that privilege is real. But that hard work is irreplaceable. I went to a school in the Caribbean, where there's a lot of stigma, especially when you're seeking residency in the US. And I just I worked really hard. I turned off all of the social stuff that I prioritized in college. And I, yeah, I just I worked really hard. And I studied all day and socialized very little. And it was it was awesome. It was incredible. And I felt like a sense of freedom, which is a weird thing to say, I still look back on that time fondly, where, like, I'm sitting at my desk in the library.

14:17 I'm just I'm going hard, right. And all of pharmacology and physiology is literally in my brain, I'm writing down mechanisms and pathways. And it was awesome. And just kind of dedication to your craft. I felt incredible, like in those moments. So I think when I look back, it's, you know, it's being a Caribbean medical student, it's not being this incredibly kind of smart person. It's matching into not my first year program. That was not the story that I was telling people externally. So I think internally, I, I felt, I felt uneasy. I was definitely depressed for a lot of that journey. I felt, yeah, I felt misunderstood. And, you know, I would tell people, well, you know, my, my goal one day is to practice, but then do something else.

15:17 They're like, you're crazy. You're out of your mind. Like, why are you spending all this money going deep into debt? This doesn't make any sense. So I think from the outside, I heard a lot of no, you can't. And from the inside, I heard a lot of, like, you're never going to get there. Okay. Yeah. It's a, I think a lot of people who go to Caribbean med school, such as myself, I went to one as well, struggle quite a bit with imposter syndrome and defining success with USM Lee board scores. Yeah. Isn't a success. I think success is when your day is complete in itself and you are looking forward to more days, but you don't feel like you're missing out in the day in itself.

16:05 Let's talk about your first non-clinical job from what I can see here is a bio show. And how did that come about? And how was your experience there? Lesson number one, the power of networks. If you remember, I mentioned, I grew up in a very tight knit mosque community, third year of medical school. I asked one of the elders, you know, how is your son doing? I'm living in Brooklyn. He's like, Oh, right, honey, you gotta go meet up with him. You know, he's working on a cybersecurity startup. That's point number one. So I just go to meet with him. And then I have a chance encounter where I'm like, Hey, look, man, I'm looking for opportunities.

16:57 And he's like, Oh, you have to meet my friend, Neve. She is the CEO of this really cool, like meta genomics infectious disease startup called Biosha. And I'm like, cool. He's like, Hey, I'm happy to introduce you. Right? Yeah. Yeah. chance encounter number two, I didn't plan any of this, right. But I think what I plan was I was curious, I asked questions. And I was always really open to meeting people and kind of taking people tape taking people's, like introductions and directions, even if there wasn't a tangible, like outcome, right? Yeah. Oh, you know, my friend, dude, he connects me to Neve, because they went to high school together, right? Power of networks. And, you know, we we hop on a phone call. And she's like, right, hon, I think you're great. You're wonderful. And she hired me as an intern.

17:51 And I, you know, so I worked with her on clinical research, on market research, it was my first taste of what business development or growth at a startup looked like I had, I had no clue, I had some kind of academic training, right? In terms of entrepreneurship and accounting and marketing, but this was my first taste of what being an operator, right, might look like. And it was a blast. You know, I was interviewing clinicians, and I was interviewing people. And it was a blast. You know, I was interviewing clinicians, I was asking them, hey, you want to buy this thing? What proof points do you need? I was talking with our engineers and data scientists on, hey, how do we build a report of antibiotic resistance? I'm like, oh, wow, that's awesome, man, right?

18:38 I was working on some really next generation technology, you know, using artificial intelligence to sift through whole genome sequencing data, right, building a microbiome profile of bacteria, virus and fungus from any human sample, right, whether it's stool, urine, blood, like, this is dope. Right. So it was a taste of the future. And I just I started learning what venture capital meant, you know, fundraising rounds, customer acquisition, you know, terms that were at that time foreign to me, that were now I'm using them every day right every week.

19:21 But it was it was an immersive experience. And I didn't really know where it would lead, but I knew that I loved it. Okay, perfect. Let's talk about how to sell into health systems. And I know this is part of it. Yeah. It's a very big topic. And it's something new founders who are not in the clinical world struggle with quite a bit. Yeah. What are some of your tips into how to get in touch with decision makers? How to best find the balance between patients, providers, and payers? Yeah. Sure. Yeah, I think kind of just continuing the story with Biosha, you know, they they raise around, and then they hire me full time. I leave residency.

20:10 And that was four years ago, and I haven't looked back. I think what I've learned at kind of a couple of companies where I've served as an operator, I now advise three startups, I launched my own consultancy called Connectify Health, connecting startups to investors, connecting startups to customers. It's really about playbooks, right? It's learning fundamentals about like US macroeconomics, like healthcare macroeconomics. It's learning about all the learning about all the misaligned incentives. Once you learn the fundamentals, you learn, like, the misincentives, you actually then learn how you can make money, but then how you can actually make the system better.

20:52 What I typically say is kind of also putting on my, like venture capital hat, right, my investor hat. In healthcare and health tech, really, you've got to pick, you've got to pick an arm, right, you're either SaaS or your services. And if you're SaaS or software as a solution, typically a higher margin space, which investors, especially venture capital love, because it's easy to scale. And there's a real appetite from customers to buy that type of product. So, you know, if it's high margin SaaS, you know, there's an opportunity to sell that SaaS B2B or business to business into enterprise customers, which are hospitals and health systems.

21:43 And, you know, typically that SaaS is priced differently. It can be per user SaaS feature set pricing. You know, there's various features. So I'm paying for that in a tier manner. It could be consumption or utilization SaaS, right? The more you use it, the more you pay for it, the less you use it, the less you pay. And, and there's a real appetite from, you know, individual hospitals, but larger health systems that are now buying, you know, SaaS platforms built by digital health startups, you know, everything from front end scheduling, higher off, you know, patient experience, right, video telemedicine, patient chat, all the way to EMR, you know, patient documentation, kind of backend billing, coding, RCM, kind of top layer, you know, data analytics, interoperability. There's a lot of SaaS that's out there that's required to modernize our healthcare infrastructure.

22:49 I mean, typically for a lot of hospitals and health systems, like the first SaaS that they bought was EMR, right? Right. So in the US, that's, you know, Epic, Cerner, you know, eClinical Works, Athena Health, EMR was built for coding and billing, it was not built for clinician workflow, right? So we've now seen lots of SaaS companies that are either building on top of EMR, on the side of EMR, or they're building newer EMR companies, you know, transparently, right? And they're also then selling into not just health systems and hospitals, they're also selling into other digital health care delivery organizations that are on the services side, right?

23:31 So we're now kind of seeing different, different customers, you know, emerge, if that makes sense. So there's this the B2B kind of SaaS market. Then if you're kind of on the services side, thinking about, well, who's the customer there, right? It's typically it's the employer, the health insurance payer, right? Kind of your more kind of B2B to C motion. Typically, a lot of that upstream was, hey, go direct to consumer, right? D2C, B2C, right? Run some Facebook and Google Ads, acquire customers online, sign them up for a service, get a couple of hundred paying customers, right? Kind of your, your typical kind of a monthly subscription, yearly subscription, and then provide some type of service, right?

24:21 Whether it's telemedicine, virtual care, patient education, pharmacy delivery, you know, so on and so forth. So we've saw we saw a lot of that like direct to consumer channel really pick up in the beginning of the pandemic. But we've now seen a lot more activity with like your kind of B2B to C channel, right? It's like I'm selling into employers for employees, I'm selling into payers for beneficiaries. And then also pharma, right? Pharma is also a buyer of digital health products. And it's oftentimes not top of mind for a lot of digital health builders, right? I mean, we count pharma as a provider, kind of similar to hospitals and health systems, they're buying SAS, right? And, you know, pharma, they want to, you know, they want to make and sell drugs.

25:16 And in the making of drugs, they're doing clinical trials, they're doing patient recruitment. So if you have data on patients, especially patients with rare diseases, and you can actually help enroll them into clinical trials, pharma will pay you a ton of money, you know, to do that. And then on kind of the selling of drugs, if you have platforms where you have lots of patients and you have lots of physicians, right, who are being marketed to buy pharma to sell the drugs, to prescribe the drugs, they're going to be paying for advertising all day long and other kind of like pricing models. So, and those are kind of your general customers that you can sell into. If you were to start a company or launch a company right now, and I know you just joined a company and we'll talk about that in a bit.

26:04 Yeah. What vertical would you focus on? Would you focus on bundling services together? And what I'm trying to get at is, there's a lot of new startups focusing on clinician workflow, and improving it, collecting our history for us doing patient follow up. But there is no direct billing codes, generally, at least for collecting our history for us. Is that a space you're interested in? And what would your advice be to someone who is in that space? Yeah, you know, I, like, so I typically think we're in the early innings of innovation, which means that, look, I mean, we are still 10, 20, 30 years away from shifting this very archaic analog, still paper first system in many ways.

26:51 You know, I think this world that many of us are building and kind of imagining towards is still a future world, right? So why I'm saying that is that I am still very bullish on digital health infrastructure companies, you know, who are kind of building the roads, the bridges and the tunnels. So, you know, EMR data is siloed, right? So I am bullish on interoperability, fire, HL seven, how do we build better just bridges between siloed platforms? I am also just bullish on data and analytics, like, cool, we now have data going back and forth. How do we make sense of that? Right? clinicians don't like data, they like decisions. Yeah.

27:34 So I think decision intelligence is, is something that I am really like in the future, very bullish on, right? So I think when you talk about workflow, and I think that's where we're getting to, we're getting to a place where, how do we make EMR data, but then other data sources, claims data from payers, you know, subjective patient and family data, right? So like, I don't really care about remote patient monitoring, like, you know, a stream of blood pressure and blood sugar, that doesn't mean much for clinicians. But I think what what's meaningful for us is, hey, what's the most important thing for us to do? So yes, I'm a human being. I'm like Can't you accept, can I make an intervention, musical change, like interventions even human risk to us? Like I would actually love to see a patient create cloud motivation to figure out what to do and I think it's best to put events together between means of measure that we need.

28:20 Which is killing. Yeah, so there's situations where health equipped walnut is, you know, contributing to a person's health or then you really end up with the fact that we're like, what can you do? First of all, where do I order a lab? When do I order an imaging? Where can I make a diagnosis? Where can I change a medication and so on and so forth? So those are the decision points that I believe really smart platforms can build. And there's a wonderful space of CDSS, right? Clinical decision support software. And a lot of these platforms right now are, they're sidebars in lots of web-based EMR.

29:04 And they're aiming to kind of build some of that at the point of patient care workflow where now I am charting in the EMR. I have this intelligent sentient thing on the side that is flagging certain things I'm typing or it's bringing forth some really deep data point from a visit last year. And then it's telling me something that is not top of mind. And now it's actually offering some recommendations and suggestions in terms of decisions. I think that is the world that we are building, but we're not there yet. Interesting. It will be important to whoever does this is not to contribute more to alarm fatigue because we get way too many notifications as it is.

29:47 Yeah, yeah. And I think that a lot of that is really version one, right? Notifications and alerts, which is noisy, right? I think the signal will be, hey, we have ingested all of these data points, right? And now I'm telling you, Rashad, this is a decision you should make. Do you agree or not, right? That is the world where we actually can free up clinicians, administrators from typing, right? And being so kind of plugged into our pagers and portals and whatnot. And that can really free us to kind of really work on those complex decision points that we are trained for. Yeah, I think this is not specifically a medical or a technical issue.

30:32 It's more of a regulatory political issue. You are a big proponent from what I've seen of patients practicing at the top of their license. Yeah, so talk to me a bit about that. Yeah. And I am as well. I think if patients accept, with ownership comes accountability. Right, yeah. There should be a shared liability model. If someone says, I have a UTI, I've done a depth stack and it confirms it. I would like this medication and my renal function's okay. They should be allowed to have that medication.

31:12 The worry there is people will abuse that system and use it for opioids or stimulants. Do you think that is a significant worry? Should we be worried about that? And what are your frank thoughts? And I'll give you one more thing. In Portugal, after they decriminalized drugs, there's been known to be a steep decline in drug usage. So just because things are available does not necessarily mean people would use them. Yeah, agreed. We need safeguards, we need a process. We need workflows that make sense. I am not in favor of decentralization without regulation.

31:56 I can provide further context around this. I was recently in Las Vegas for the Health, the conference which gathered 10,000 plus health tech innovators and kind of speaking with kind of friends and kind of change makers. I think what I realized is that like, there are really big macroeconomic problems right now that are being discussed, but we're not talking about the solutions to address them. What I've been talking about kind of mostly ad nauseum is that look, we have increasing care demand across all verticals and demographics, but especially amongst our aging population.

32:37 Polychronic, polypharmacy patients, three, four, five chronic diseases, they're on seven, eight, nine medications. These are the sickest, riskiest, most expensive patients in our collective health systems, whether it's the US or Canada. And when I think about those patients specifically, but really any other patient, right? And especially like patients with chronic disease, the problem on the supply side is that as demand for care is going up like this, the supply of providers is going like this. So there is a gap and that gap is the biggest problem in our system.

33:23 A lot of people talk about cost. I am not of the thought that cost is going down or will go down, right? I am of the thought that look, in the US healthcare is approaching 20% of GDP, it'll probably becomes 25% of GDP. And I don't think that's a bad thing, right? But I am not of the thought that we will meaningfully be able to decrease cost, right? I am on the opposite side of like quality, right? How do we improve quality? But a lot of that quality depends on supply of existing providers. And what we are seeing and the pandemic accelerated that is that physicians, nurses, mid-level providers, therapists, aides are leaving the profession.

34:07 We are not building more nursing schools, medical schools, residency programs and fellowships, right? These are usually federally funded, federally mandated programs. So like, yes, we will need a generational change in leadership from the top. Folks who realize that, well, we've been talking about provider shortages forever and we're not doing much about it, right? That is still our biggest macro problem. And in the US, for example, last year, 10% of all physicians left the clinical workforce. That is an alarming statistic. And we keep hearing, and it's not just older folks who are retiring, it's people in their 40s and 50s, right?

34:51 So what does that mean? I think what that means is again, what we in digital health can do is, there's really only one of two solutions the way that I look at it, right? Like telemedicine is a tool, it is not a solution, right? It requires a physical person on the outside, physical person on the other side that currently does not exist, right? So the way that I look at it, there's really one of two macro solutions. Number one, we need to build a new industry, a new workforce of non-clinical frontline staff. You know what? Yeah. I'll just say one thing.

35:33 Vinod Khosla of Khosla Ventures, that's his vision as well. Yeah. And I think his vision is that the people who are in the industry will be actors. Right. But sorry, I'll let you continue. Right, and again, this is not, and I think a lot of the folks in venture, right? Vinod Khosla, Himant Taneja, and his theory of health assurance, his work at Lavongo and the work at General Catalyst, he's the only one who has this idea of, the only way that prevention works is that we are, again, building this newer workforce of folks who are keeping us healthy at home so we're not utilizing the system, right?

36:19 And are they liable for the care the same way we are when we prescribe pre-dense? So I think liability comes next. And why I say that is that, people are going to be more the non-clinical folks, right? So I think we've seen at various digital health care delivery startups, it's the care navigator, the care concierge, the patient engagement specialist, right? So these folks are like customer success, right? They're being hired from retail, consumer, like non-healthcare, hospitality, right? That is traditionally what we have lacked, right? It's that understanding of consumer, right? I think is a good thing, you know?

37:01 Like clinicians and practices, we're not trained on that, right? Like why do we have a waiting room? A waiting room is antithetical to ideal consumer experience. Right? There is a tension there between what the patient wants and what's best for them. That tension doesn't really exist in the hospitality industry or the food industry is, if I want my food, my steak cooked more, cooking more. Exactly. You know what, we do have those ethics in clinical medicine. What's the first ethic? Autonomy. Yeah. So, I mean, autonomy really means like, hey, I want what I want. So our job should be facilitating that autonomy, but we still have paternalism.

37:45 We know better than you. So there is no true autonomy in medicine, I would argue. And there is no true informed consent because, you know, we go to school for 12 years. It just cannot exist. And we can go deeper into this. Yeah. I would ask you, would there be balance between what the patients want and what's offered to them? And if there is a balance or a line in which they say, okay, you cannot get more morphine or you cannot get antibiotics for this viral infection, even if it might have some anti-inflammatory properties and help a little bit. Yeah. Where is that line? Who decides where that line lies?

38:25 Because right now we decide. And again, then who's, you know, I get stuck on liability when I think about this. And I think that's why it hasn't happened. Yeah, you're wrong. I don't, you're not wrong, but I think to kind of provide some more, and we'll get back to liability, but I think to provide some more context around my previous point where first is like this workforce of non-clinical staff, right? The second part is, well, how are we enabling self-service? This idea of, you know, patients are craving education because they want to treat themselves. And that is not going away by the way, right?

39:07 So the world that is a reality right now that I think a lot of clinicians understand, but just don't understand the implications of is, there are people going on TikTok and going on Google and self-treating, and that will only continue with platforms. So I think the correct way to guide that is say, hey, that's wrong, don't do that. It's more of let us build platforms to enable you, I think to your point with proper liability, safeguards and regulation, right? So what I mean by self-service is this idea of, how do we enable patients to practice at the top of their license, right? Which means education, rich multimedia, evidence-based information, which is sorely lacking right now.

39:54 Like that content exists, right? But it's not being delivered to patients at their fingertips, right? And where are people? They're online, right? They're on TikTok, they're on Google, they're texting. Like that is where, you know, the ethos of evidence-based clinical medicine needs to be. And right now it's siloed at conferences, it's in publications, right? It's sure, like your clinician in the visit is telling you that, but in one ear out the next, right? So that is where digital health through SMS-based workflows, through kind of automated CRM type platforms, right?

40:37 Where we can text, we can email, we can remind. I think that is the connective tissue that is currently missing that we need, right? To enable that to happen, like, you know, just provide people with information that is trusted, that is vetted. So I am not in the wilderness, right? I am given a diagnosis that is earth-shattering. Yeah. Want education and information. And I'm not getting enough of that from my very busy provider in the 12-minute visit that I had, right? Yeah, I have way too much to say about this, Rehan. I'm sure you do. I think, I do think this is the future. I think it needs to happen.

41:18 I am not convinced patients, in my experience, and I may be biased because I work in urgent care a lot, and that is the bulk of my patient experience, I am not convinced they would be happy with being kind of shown, okay, this is your diagnosis, these are the treatments we'll offer you at the end. Like, currently we're practicing medicine to maximize billing, reduce liability, which partly is to make sure patients are satisfied. I think a strictly evidence-based system will leave patients more dissatisfied from what I can see. And I would love to be wrong on this because I think there's so much room for increased access.

42:00 I don't know, I don't disagree with you, right? What I think, what we are slowly seeing the building of is a hybrid model where there is shared decision-making and shared liability, right? What I imagine is, yes, there's patients, but then there's also peers, and there's also family and caregivers. So how do we enable family to practice at the top of their license, right? We have a caregiving crisis, right? There is unpaid labor, right? So do I imagine the payers actually paying family? Yeah, I do. And I think that is kind of the logical extension of, look, we have provider shortages, who can we pay to help patients be safe at home, family, duh, or the people who are there?

42:50 But again, how do we enable those folks through education, through support, through resources, through these types of real-time platforms? Then how do we also share that liability? And I agree with you where, you know, if there's platforms where, okay, cool, I have self-diagnosed, I am now taking this medication, but something went wrong. Who are we gonna sue? Am I suing myself? Exactly. Yeah, look, I think yes, I think there will have to be these new kind of newer liability frameworks where I am signing waivers and I'm saying, hey, look, you know, I cannot sue this AI algorithm. I cannot sue the company that made this. I can't. And I think that is this newer contract, this new kind of shared decision-making.

43:34 And I agree with you where, you know, the brother of autonomy is liability and responsibility. No, I completely agree. I would love to see that in a marketplace. I hope I'm wrong. My initial instinct is people would not accept that because generally people don't wanna accept their own faults and if they made a decision bad for themselves or worse for their loved one or for their child. Let's talk about guaranteed. Let's talk about, give me a brief introduction on guaranteed is and what you're most excited about and some obstacles you foresee guaranteed facing. Yeah.

44:15 So, you know, death is guaranteed. And the reason why we chose the name is a good death is not necessarily guaranteed. So, you know, you can't choose what happens to you, but you can choose, you know, what to do about it. So, I think that is the way that we are looking at kind of reframing conversations around death and dying and imagining a more modern end of life care experience. One that is radically different from your picture of, you know, a frail, you know, aging person who's in a hospital gown, hooked up to an IV, you know, in a like desolate and sad room.

45:08 What we are imagining as a kind of disruptive consumer brand is the exact opposite. It's colorful, it's full of life, right? We're helping you die better, right? So this idea of die how you live, but that really means we need to find out how you want to live. And the way that we look at end of life is about honoring your wishes, your desires and your demands, autonomy, right? Idea of learning from consumer, which is tell us what you want and we'll do it. And that's really what the best hospice care should be. Yes, we talk about pain management and symptom management, but those are more of the tools and the modalities.

45:55 It's not the purpose, right? Yeah, you know, in my experience and I've taken care of quite a few people, patients in their end of days, there is tension between staying alert, aware and reducing pain and suffering because of the medications we use can cause drowsiness. A good death for me, and for our listeners, euthanasia actually means good death in Greek, although the word has different connotation in our culture. A good death for me is where my autonomy is maintained for the very last second. A good death for me is euthanasia, being frank. And I go on my own time, date and where I want to be.

46:40 What is a good death for you, Rehan? And how do you phrase that conversation with patients? Yeah, I wanna be very clear that, you know, we definitely respect your thoughts and wishes. We look at it a little bit differently. You know, our philosophy at Guaranteed is simple. Everyone deserves to live and die with dignity and comfort. So our health affairs are deeply personal, and it's not shaped just by medicine, but it's also by our lifestyle, culture, faith, personal ethics and more.

47:20 So, you know, euthanasia, you know, that may be a desire, right, by some, but that is not the way we are looking at the sum totality of human experience, right? So for us, this idea is that we need to be radically personal, inclusive, and very hands-on, but really kind of celebrate those differences. And we have not seen that previously with end-of-life care, right? And one example, for example, is spiritual care. You know, there is a diversity of, you know, faith and non-faith at the end of life. So we should be providing folks who are trained in both modalities, and that's currently not available in our system, right?

48:06 You're lucky if you get a chaplain, right? Part of a really good, you're even luckier if you can say, hey, I am X, Y, and Z faith. I am looking for X, Y, and Z, like spiritual counselor, right? So that is the way that we are thinking, you know, in terms of choice and optionality, if that makes sense. No, that makes sense. What are some obstacles you see for guaranteed on their growth trajectory? I think there's lots of obstacles in terms of the healthcare system that we are operating in right now. Yeah. We have a fractured medical system, opaque information.

48:46 You know, we're operating in a for-profit space that is light on regulation. There are bad actors at play here. There's lots of suspicion around hospice. Frankly, lots of providers who are not palliative trained don't trust it. And that's partially due to bad experience, right? So we are up against a lot and we are, I think our biggest barrier is stigma, you know? Talk about death at a dinner party and see what happens. Yeah. So, you know, it causes fear, you know, it causes anxiety. So I think for us, there's like a wider societal reframing that we need.

49:32 And I think the way that we do that is we try to relay that. Like we are a care company that makes those tough moments easier. So let's start with having conversations there, right? And then we can delve into our hybrid care model, right? How do we do, you know, self-service, virtual care, in-person care, like that stuff comes later, right? When we talk about the technology that we are building here. But I think it's really just around conversations and having that consciousness about my end happen much earlier than it's happening right now. And then those discussions happening in non-medical spaces, right?

50:16 That is the struggle, right? It's not, you know, your typical hospice is getting referrals from, you know, skilled nursing facilities, assisted living facilities, health systems, hospitals, outpatient practices, right? That is how a lot of the business happens. However, people are still choosing where to send their loved ones. And, you know, you have a community of people who you trust. So how are we talking to those folks that are trusted? It might be your church pastor. It's the barbershop owner. You know, it's the person, you know, you see at the grocery store.

50:58 It's your friends, your family members. These are non-clinicians, right? Those are the people you trust. And if somebody is like, hey, look, you know, I saw this really awesome service or I use this for mom, you should take a look at them. You are much more likely to follow that recommendation than actually going online, Googling something, reading all the reviews. That still happens, right? But, you know, so there's various, I think, modalities of having those discussions, right? That is outside of our general clinical system. Okay, perfect. Rayhan, if you had $10 million in your bank account tomorrow, and maybe you already do, I don't know.

51:39 I don't, but yeah. What would you do differently the day after? Yeah, in terms of innovation? In terms of your life personally, would you- All my life, yeah. What is the end goal for you? What are you working towards? Yeah. And how do you know you've arrived there? Yeah. And being an innovator of companies and working along great entrepreneurs, or is it something more personal, like you would retire on an island and catch fish all day? Sure. You know, I already feel like I've made it. I don't feel that, you know, I will make it. And I think that that philosophy has served me well.

52:21 I am very lucky to work at a company that has been funded to some degree. But I think personally, you know, for me, it's all about service and impact. How am I utilizing that money? And money is a tool, right? It doesn't really mean much if I can't empower the right people and build the right processes and the services to scale that money. So that could be philanthropy, that could be backing underrepresented founders, that is charity, right? It is just helping, you know, enable folks who are already working on really difficult problems, whether that's poverty, malnutrition, housing, like it's really basic, simple things across the world, right?

53:08 I'd love to give back, you know, to South Asia, give back to my homeland, like where my parents came from. Education is always very top of mind for me. So I think I would ideally use that money in various ways to give back. Do you have time for one more question, Rayhan, or do you have to go? Yeah, sure. So this is an idea I've been playing around with about identity. Our identities and things we identify with, you know, brown, male, Southeast Asian, religion, they empower us, but they also divide us. What are your thoughts on these different identities?

53:50 And do you think the goal should be, and this is what I think the goal should be, is for race, religion, countries to essentially not exist because I see them as a divisive force. And this is based on my experience in childhood where there were a couple of riots I was involved in where there were people out to kill my kind of people in India. So I have a very biased view on this and I recognize that bias. Let's start with an easy one or an easier one. Do you think countries should exist? I don't think they should, but because I think it's a made-up concept and doesn't make sense to me.

54:30 And then let's go to a harder one. And I won't pick on race or religion because that's a much longer conversation, but I will ask you, do you think gender should exist? These are really weighty questions. I think I look at things slightly differently. I think the purpose of difference is for knowledge, empathy and connection and ultimately unity. We are all reflections of the beauty on this world. Yes, there is ugliness and trauma and tragedy, but that is also required to understand what is beautiful and what is good and what is right and what is just.

55:19 So I think our purpose is to know each other. So difference is beautiful and to be celebrated. What I believe is that oftentimes it's about understanding humanity and universality. That does not mean conformity. So I can be from X country and you can be Y country, but we can be united. And I think in history, we have seen examples where there are superseding types of unifying parameters where folks, they're a part of a greater good. They're a part of a greater collective. And I think that's a very human, it's a very, it's a very, it's a very, it's a human, it's one of our essences.

56:06 We were created to connect. We were not created to be lonely. One definition of loneliness is also, it is a separation from yourself. Yeah, so this idea of you actually need to connect to yourself, but once you connect to yourself, you understand who you are, then you have to actually, there's a requirement, I think, to connect to others, to understand creation and to understand purpose. But that requires an understanding of difference. But then really seeing that difference is not, that is its form, but that at our elements, we are actually all alike. Like you and I are mirrors of each other, and all of these kind of superficial, I agree, kind of societally constructed labels of I and you, American, French, he or she, these are not helpful.

57:04 I like to quote the famous Rumi who said that, there is right and then there is wrong. There is right doing and then there's wrongdoing, but then there's a field. Let's go hang out on the field, right? So that's the way that I look at it, that I wanna see beyond just seeing, right? There's connection of the heart, there's connection of souls. Now we're getting really kind of philosophical and spiritual, but these are just the clothes that I wear. It's an artificial dress that I'm putting on, but I think our purpose really is to know each other. But I think those differences are educational though.

57:45 It helps us to kind of understand the beauty of creation. Do you think there is a soul or do you think we are pathways and algorithms connected in a middle? I do have to hop, but look, that might be a great part two of the podcast. It was great hanging out, Rehan. We'll have to do it again. Yeah, wonderful. Thanks so much for having me on.