Innovation experts have long overlooked where a lot of innovation actually happens. The personal computer, the mountain bike, the artificial pancreas — none of these came from some big R&D lab, but from users tinkering in their homes. Acknowledging this reality — and encouraging it — would be good for the economy (and the soul too).
Category: Uncategorized
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#29 – Powder Diets, Instagrammable Experiences & Distribution First
The Hustle’s My First Million presents: Million Dollar Brainstorm is back. Host Shaan Puri (@ShaanVP) and The Hustle CEO Sam Parr (@theSamParr) sit down and discuss what side hustles, trends and big business ideas that’s keeping them up at night. This time, it’s live with you guys who came to the Trends meetup last Thursday and answered some of burning questions.They also explore this week powder diets, turnkey instagrammable moments, building products around the distribution & why Facebook groups is the place to be.
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Jane Goodall: Biologist, Teacher, and Inspiration
Jane Goodall shares remarkable lessons from her life abroad and talks about current issues such as climate change and her hope for the future in this episode of Guy Kawasaki’s Remarkable People podcast.
See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.
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Ryan Graves, Advanced Navy Fighter Pilot and UFOs (#34)
Ryan Graves, an F-18 advanced fighter pilot for the Navy, has engaged with UFOs. Kevin goes into all the details along with discussing the Department of Defense release of UFO footage.
This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.kevinrose.com/subscribe
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Of Container Ships, Supply Chains, and Retail
AI transcript
0:00:06 Hi everyone, welcome to the A6NZ Podcast. I’m Sonal. In this episode, we’re resurfacing
0:00:11 one of our favorite episodes on one of the most seemingly boring, but not to us, topics,
0:00:15 container ships, the logistics of supply chains, and more. In this episode, first recorded
0:00:21 over two and a half years ago in Washington, D.C., we interviewed the box author Mark Levinson.
0:00:24 Here’s the original intro with more details about what follows.
0:00:29 Hi everyone, welcome to the A6NZ Podcast. I’m Sonal. Today’s episode with me and Hannah
0:00:34 is another one of our podcasts from our recent road trip with voices from the ground in Washington,
0:00:38 D.C., though this one actually takes us all around the world. Our guest is economist,
0:00:42 historian, and journalist who was last at the Economist, Mark Levinson, the author of the beloved
0:00:46 book, The Box, which is about how the shipping container made the world smaller and economy
0:00:51 bigger. But this Hallwaystall conversation is actually a quick tour through all his books,
0:00:55 starting from his most recent one, An Extraordinary Time, where we touch briefly on the topic of the
0:01:00 golden age of productivity and beyond, to the topic of the death of retail and his book The
0:01:06 Great A&P, to finally wrapping up on logistics, transportation infrastructure, supply chains,
0:01:10 and touching very briefly on the future of work, and where government comes in policy-wise and all
0:01:15 this or doesn’t. We’re so excited to have you. Welcome, Mark. Thank you. Glad to be with you.
0:01:20 So those seem like really different topics. What’s a big idea that drives the thrust of
0:01:25 your work that kind of connects all the dots? I’m really interested in the connections
0:01:34 between economics and the world we live in. A lot of my work starts out at a microeconomic level,
0:01:40 looking at particular companies, looking at particular industries, and tying the developments
0:01:46 there to broader trends that really affect how we live, affect our standards of living. More
0:01:53 recently, I’ve been focusing on some of the trends in productivity growth because I believe that a
0:01:58 lot of the improvement in our living standards really comes out of these kind of micro improvements
0:02:04 at the private sector level rather than as a matter of great policy. And what that means,
0:02:08 and this is a frustration for public officials, is that there are no easy government solutions.
0:02:16 We’ve now been through generations in which politicians and the economists who advised
0:02:22 them said that they had the cure for poor productivity growth. I argue in an extraordinary
0:02:28 time that actually this was what was behind the political swing to the right in the late 1970s,
0:02:35 early 1980s, when we got Margaret Thatcher and Ronald Reagan. Because the more social democratic
0:02:41 type of governments before that hadn’t been able to restart productivity growth. And so voters
0:02:47 turned to people with other ideas, but the people with the more free market ideas proved no more
0:02:52 successful than the people with the more statist idea. What are we actually comparing to as we’re
0:02:57 thinking about these ideas? Well, this is not good enough. What are we holding up as something
0:03:02 that we’d prefer it to be? The end of the post-war boom and the return of the ordinary economy.
0:03:10 The story I’m telling is that the quarter century after the war was an unusual period of very rapid
0:03:19 economic growth. The period from 1948 to 1973 was probably the period of the fastest economic
0:03:25 growth in the history of the world. GDP around the world grew at more than 5% a year. Now,
0:03:33 at 5% a year, something doubles in 14 years, quadruples in 28 years. So even with some population
0:03:39 growth, people’s incomes were growing very rapidly. People’s living standards were rising
0:03:45 in a way that was visible to them. They were able to buy houses for the first time and cars for
0:03:51 the first time and send their kids to high school and maybe even college. And we had all kinds of
0:03:56 very rapid advances in living standards. What was that due to? What was the big driving force?
0:04:03 We had an unusual confluence of factors in the post-war period that people have really forgotten
0:04:10 about now. One is that there was a great deal of underused capacity, underused resources in the
0:04:17 economy. I’d like to remind people that at the end of World War II, we still had 3 million mules
0:04:21 on farms in the United States. Wow. It’s such a technical post-industrial revolution time. You
0:04:28 don’t even realize it. You had millions of people, and not just in the United States. European peasants
0:04:34 and Japanese farmers are owned half an acre of land who could be moved from very low productivity
0:04:40 jobs into very high productivity jobs in the cities. And we had a lot of that in the 50s
0:04:48 and 60s. So that was one big boost to productivity. We had very rapid increases in education levels,
0:04:54 and we know that education is associated with productivity. In the United States at the end
0:05:03 of World War II, going to college was not common. Just a few percent of the population of 18-year-olds
0:05:08 actually went on to college. And the average education level was around eighth or ninth grade.
0:05:14 So in a very few years, governments spent a lot of money building a more educated workforce,
0:05:18 and it paid off. The government was the one that seeded that, or was that just a shift in the fact
0:05:25 that adolescents existed and childhood change? No, this was heavy expenditures, building universities
0:05:29 all over the place. Take a look at how many universities in the United States started after
0:05:34 World War II. That’s when a lot of government money started. It was no longer an elite thing
0:05:39 to go to university. And how about women entering the workplace? Well, women entered the workplace.
0:05:44 The other thing I think that was really consequential in this quarter century, I’m describing,
0:05:49 was that we had the growth of motorways, the interstate highway system in the United States.
0:05:53 So public infrastructure, like the transportation infrastructure. And think about what that does
0:05:59 if you are a manufacturer or a retailer that lets you sell over a wider area, lets you operate
0:06:04 your facilities more efficiently. You don’t need a warehouse in every town. You can have one little
0:06:09 serve a large area. If you’re an employer or a worker, it’s changed the size of your labor market.
0:06:16 I mean, in Silicon Valley, San Jose and San Francisco are now part of the same labor market,
0:06:20 right? That wasn’t the case after World War II. These were very different cities and they were
0:06:27 a considerable drive apart. And so that creates a better fit between people and jobs and then
0:06:33 leads to higher productivity. They can’t be repeated. Once you’ve moved those sharecroppers
0:06:41 to the cities to take jobs in industry using heavy machinery, they’ve moved. And you don’t have
0:06:46 those underused resources again. There were countries around the world that literally went
0:06:54 25 years from 1948 to 1973 without a single year of recession. We had countries that had
0:06:58 less than 1% unemployment back then. So how did this burst of productivity,
0:07:04 this golden age actually come to an end? Well, in 1973, we really saw a trend change.
0:07:09 That was the year of the great oil crisis that some people may remember.
0:07:15 What we have moved into since 1973 is really an environment in which economic growth has been
0:07:20 slower. The improvement in living standards has been slower. The unemployment rate in most
0:07:27 countries has been permanently higher. We have not been able to recapture the very unique good
0:07:33 times that we had in this golden age. And I think that we’re not going to be able to.
0:07:40 What we’re experiencing more recently is actually normal. This is the way most economies work most
0:07:45 of the time. And how it worked before this golden era? The golden age was actually the exceptional
0:07:51 time. It’s not normal that economies grow at a rapid pace. It’s not normal that incomes double
0:07:56 or triple or quadruple in the matter of just a few years. And I don’t think we should expect
0:08:00 that to recur. I view this as analogous to child development and how human body and adult develops
0:08:05 because there’s a rapid development that happens in the birth of a child. And then there’s another
0:08:09 big rapid issue that happens in adolescence. And then you continue to grow, but it’s a little
0:08:15 slower. And in fact, thinking about the natural conclusion of your argument is that that growth
0:08:20 is now shifted to other countries like India, China, where they are now experiencing the kind of boom
0:08:27 that you were describing that happened pre-1973. That’s a great analogy. Take Japan, which in the
0:08:33 1960s or early 70s was growing at seven or eight percent a year. And then it downshifted. And then
0:08:38 it downshifted some more. More recently, China went through a period where it was growing at ten
0:08:43 percent a year. In China’s case, we do have to take the numbers with the big grain of salt.
0:08:49 Even so, people were extrapolating and saying, you know, when China grows at ten percent a year
0:08:53 for the next century, its economy is going to be twice as large as the rest of the world put
0:08:58 together. But China’s not going to grow at ten percent a year for the next half century. It’s
0:09:04 becoming much more like a normal, mature economy in which the growth rate is a couple of percent a
0:09:09 year. And that’s all they’re going to be able to expect. But it doesn’t mean necessarily that,
0:09:14 like in adolescence or growing as a human being, you only get one burst. These things can come in
0:09:17 waves. There can be other kind of confluence of these factors. When you were talking about the
0:09:22 Japanese farmers with their mules and the sort of move towards the way automation may end the move
0:09:27 to cities, increased productivity, are there any inklings that you’re starting to see of
0:09:31 possibilities like with the automation we’re starting to see happen today? And maybe even
0:09:35 with autonomous cars, new infrastructure might, you know, city infrastructure, are there things
0:09:41 that give you any sense of maybe a new era might be coming at some point? Or just even a way to
0:09:46 juice the body on steroids, like just inject some more steroids into this economy? You’re asking
0:09:53 great questions here. And the answer is maybe. I think that these are things we really can’t predict.
0:10:00 If you look at past episodes of fast productivity growth, in general, they weren’t predicted very
0:10:07 well. For example, we had a spurt of productivity growth, which translated into faster income growth
0:10:14 in the late ’90s and the first years of the 2000s. This is the famous internet boom you may
0:10:21 remember. So we remember it. But in 1992, no one predicted this. What happened was that there had been
0:10:28 investments in infrastructure. There had been developments in technology decades earlier.
0:10:33 And finally, during this period of time, they all came together. But I think a lot of people would
0:10:37 argue that we’re in a moment like that again now. Well, I think that’s a question which we can’t answer.
0:10:43 So if you take a look at a technology, will it actually revolutionize the way certain industries
0:10:48 work? I don’t exclude the possibility. But you have to keep in mind that there are also a lot of
0:10:55 complications. You’re seeing this right now as we go through this rather brutal shakeout in retailing.
0:11:00 Yes, everybody knows that you can order goods on the internet. That’s not news these days.
0:11:06 But the reality is that for a lot of retailers, there’s a problem here because they’re maintaining
0:11:11 an internet business. They’re also maintaining a retail store business because some customers want
0:11:18 that. So in some cases, their costs have gone up. They have not become online retailers. They have
0:11:23 become bricks and mortar slash online retailers. Right. And they’re showrooming for the online
0:11:27 sometimes. They’ve got multiple channels that they’re having to service. And that’s actually made
0:11:31 their operations less efficient in a certain way. I would actually say there’s a flip side of this,
0:11:36 though, again, which I think is really fascinating. Because when you think about the internet economy,
0:11:39 birth of Amazon, which is less face at the behemoth and everything,
0:11:44 the everything store, everything, everything. And they recently, as we know, started
0:11:50 doing physical brick and mortar bookstores. The difference is that they started online and they
0:11:57 went into physical using data to help stock and think differently about how to create their store
0:12:02 in an internet native way in the physical world. So I also wonder if, while the debt or retail might
0:12:07 be on the horizon, if after that there might be an entirely new post boom, a new boom around
0:12:12 retail that’s completely reshaped by new technologies, we don’t know. That’s entirely possible.
0:12:18 But just to give you something to think about, Amazon’s problem in terms of getting its books
0:12:24 into its physical stores is entirely different from its problem getting its books ordered online
0:12:30 to you, the customer. Yes. So now it needs a different kind of logistical system. It needs to
0:12:36 figure out how to distribute to retail stores like the ones that apparently is building.
0:12:42 That’s going to have a lot of costs attached. It may have some inefficiencies attached, at least
0:12:49 while they’re developing it. So my point is to say that the path of, sometimes people who are
0:12:55 involved in the tech industry kind of get very romantic about how quickly these great technologies
0:13:01 are getting absorbed. But in reality, life is messy. And some of these technologies take a while to
0:13:05 be used efficiently. And some of them will never be used efficiently. There are more failures in
0:13:09 there are successes. There’s no question about that. So does it remind you at all of the sort
0:13:15 of death of the supermarket that you talked about in your book, The Great A&P? In The Great A&P,
0:13:20 I was writing the history of what was for about 50 years, the largest retailer in the world.
0:13:25 People forget this now, but the Great Atlantic and Pacific. Is that what A&P stood for?
0:13:29 I had one in my town. I didn’t even know that. Yes, it was the Great Atlantic Pacific. It was so
0:13:35 named in 1869 for the Transcontinental Railroad. Wow. And at one point, it had more than 16,000
0:13:42 stores in the United States. So it was a behemoth. It was the Walmart of its day. But one of the
0:13:48 things that kept it so vibrant is that it remade itself continually because shopping trends change,
0:13:54 consumer expectations change. From what to what? It started out as a seller of coffee and tea and
0:14:05 spices. It made itself into a small grocery chain. And then in 1912, it developed the idea of having
0:14:10 an economy grocery chain, which is to say it would have a very bare-bone store and sell
0:14:17 products much cheaper than the competition. And that’s what drove its growth in a small
0:14:22 period of years. It integrated vertically. So it made its own chocolate, its own macaroni,
0:14:29 its own canned, its own salmon. And so it then had a huge network of manufacturing plants. And
0:14:36 again, we’re in the 1920s here. And then it started building supermarkets. It was not the
0:14:42 innovator in any of these things. A&P did not develop the idea of supermarkets. But once it
0:14:48 saw how supermarkets would work and how they would fit with its business, it started building
0:14:52 supermarkets all over the place. And by the end of the 1930s was the biggest supermarket operator
0:14:57 in the country. So what ended up being its downfall? The company stopped innovating. The company
0:15:04 stopped remaking itself. It was big. It was fat. It was happy. The two brothers who had controlled
0:15:11 it for decades both died in the 1950s. And it was then run by people who had been with the company
0:15:19 for decades and whose idea was to preserve it rather than to keep it changing. The beat that
0:15:24 keeps coming up in this is basically the tension between this idea that you can innovate, but then
0:15:29 you get too good at what you do, too comfortable, too complacent. So what’s the big then lesson or
0:15:35 takeaway from that, from your work on the great A&P to this narrative around the death of retail
0:15:43 today? Retailing is full of dead bodies. People like to talk about how unfair competition is
0:15:49 sometimes because the big companies have more power than the little ones. But when you are a
0:15:54 big retailer, you can’t change so easily. If you own one store and you think you need to do something
0:16:00 else, you go in there with a hammer and some plywood and you can do it. If you own 1,000 stores,
0:16:05 you’re stuck. You’ve got your locations. You’ve got your product line. You’ve got your brand name.
0:16:11 And you can’t change easily. It’s a really difficult situation. And so a lot of stores
0:16:16 end up dead. It’s innovator’s dilemma, classic case. So another theme that’s come up and that
0:16:21 connects all the dots with this entire conversation, that this post boom world was one of the drivers
0:16:27 was this rapid development of infrastructure. Amazon exists because of logistics and infrastructure,
0:16:32 like innovations and being able to ship things and deliver things fast. We talk about the supermarket
0:16:36 and the growth of suburbs around railroads and transportation. Transportation and logistics
0:16:40 and infrastructure is like the thread that connects and drives all economies. So let’s
0:16:44 talk about the box, which is all about logistics and infrastructure in the form of container
0:16:49 shipping. You chose one very specific thing in the box to talk about. It had this massive effect
0:16:54 on a global economy. Give us a little bit of a sense of what that story was like. I remember
0:16:59 Tim describing when he pitched your book this incredible scene of just the giant
0:17:04 mountains of peanuts in the ships. Like how quickly did shippers see this possibility and
0:17:09 start using it? Was it fast or slow? Let me give you just a quickie history here. The idea that you
0:17:16 could save money by shipping goods in containers came along in the 1700s. This was an old idea.
0:17:20 And nobody had ever figured out how to make money out of it because what would happen was that
0:17:27 where you’d make a container out of wood and nailed and you’d put your goods in it and then at
0:17:32 the other end of the trip, somebody would break the container apart and use it for firewood.
0:17:38 That was a pretty inefficient system. And nobody ever found this to be viable. It actually cost
0:17:44 more to ship goods in containers. What made this whole thing work was the arrival of a guy named
0:17:50 Malcolm McClain, who was a trucker. So he didn’t come from the shipping industry. And he understood
0:17:57 that what was needed was not particularly a container, but a new system for moving freight.
0:18:02 And the container was just a piece of what… It was just a container. It was just a container.
0:18:10 And a lot of people back in the ’50s and ’60s who were in the shipping industry were very enamored
0:18:15 of their ships and they thought they were in the shipping business. And McClain’s basic position
0:18:19 was nobody cares about your ship. They just want to get their goods from here to there and let’s
0:18:25 design an efficient system for doing that. So shipping containers first came into use in the
0:18:34 United States in 1956. They started being used internationally across the Atlantic in 1966.
0:18:39 And the industry was pretty substantial by the 1970s. By that time, most of the older vessels
0:18:45 had gone out of service. But it was really in the 1980s when modern logistics took off.
0:18:50 There were a couple of things that happened. You had in this country freight deregulation,
0:18:57 which meant that you could actually sign a single contract to import products and that would cover
0:19:02 delivering the goods to a port and moving them inland by rail to a final destination
0:19:07 or having a truck pick them up and move them to a final destination. So you could actually
0:19:12 integrate all these modes of transportation and have some assurance that the goods would get there.
0:19:19 And then you had improvements in communications. This was referred to as electronic data
0:19:25 interchange. So all of a sudden it became possible to run an international supply chain
0:19:31 in the 1980s. Now you could send instructions across the ocean quickly about how you wanted
0:19:37 something shipped or how you wanted something made. And so this innovation, the container that had
0:19:42 really come about in the ’50s, started to make a substantial difference in the world economy
0:19:45 in the 1980s when we had the birth of modern supply chains.
0:19:50 The most fascinating thing to me, the idea that astounded me most about the box was the idea that
0:19:57 the containerization of moving goods was allowed things to travel multimodally. That because of
0:20:03 that, this modularization, you could now break things across ship to train to plane across the
0:20:07 world. And that is like a really eye-opening idea. And I think it’s really interesting that you
0:20:12 reference the EDI because the analogy that I was thinking of was actually packets and moving data
0:20:17 across lines like the Ethernet. And that packetization of data also led to this thing where
0:20:23 you can move things across phone lines, Ethernet lines, other computer lines, broadband, etc.
0:20:25 And essentially reassemble them at the other end.
0:20:27 That’s a good analogy.
0:20:33 It’s a really mind-blowing idea. So I guess the question I have is what’s happening next and now
0:20:38 that you think is interesting in the next evolution in supply chains that is along these lines?
0:20:42 Well, there are a couple of things that are going on in supply chains and they’re not necessarily
0:20:47 good. International trade and manufactured goods actually grow more slowly than the world economy
0:20:51 for the past six or seven years. That’s a big reversal from the previous trend.
0:20:56 Why is that? One of the reasons is that supply chains have become less reliable.
0:21:03 These ship lines went out and purchased very, very large vessels. And I’m sure your listeners
0:21:06 have seen these vessels can carry that. I’ve actually seen them firsthand because I went to
0:21:10 the Panama Canal and it’s incredible. Panama Canal doesn’t handle the biggest one.
0:21:12 That’s right, because they’re actually greatly limited by the Panama X ship.
0:21:17 The biggest container ships now at sea can carry more than 10,000 truck-sized containers.
0:21:19 Wow. That’s amazing.
0:21:24 These are enormous vessels. So what has happened? Well, imagine you’ve got a port,
0:21:30 but instead of having a ship carrying 2,000 containers showing up every day,
0:21:34 now you’ve got a ship that carries 10,000 containers showing up once a week.
0:21:38 You’ve got a mess on your hands because you’ve got this enormous load of traffic,
0:21:41 which you need to get all these containers out of the port.
0:21:43 That’s too much. Think of bottleneck congestion.
0:21:49 Yeah, that’s right. You’ve got a bottleneck. This has come at a time when growth in trade has been
0:21:55 pretty slow. So there’s considerable overcapacity in the industry, and even so, the reliability
0:22:04 has fallen. So what you’ve seen is actually manufacturers and retailers contracting their
0:22:09 supply chains. They would like to make things closer to where they’re used because they think
0:22:14 there’s less risk. One of the things that I think happened in the growth of these international
0:22:21 supply chains is that companies paid a lot of attention to cost. They said our hourly labor
0:22:27 cost in China is a lot cheaper than it is in Detroit. They didn’t really pay much attention to risk.
0:22:34 And risk is a cost factor. There were a number of US companies that failed or came very close to
0:22:40 failure because of supply chain disruptions. Key merchandise wasn’t available when they needed
0:22:44 it for their factories or for their store shops. I mean, this is the story of hardware startups.
0:22:48 The problem isn’t that they can’t plan out and predict and build. It’s that they need to lock
0:22:52 down that supply chain inventory at the right time, but yet they have the issue that they don’t
0:22:56 know how many products their customers are going to buy, so they don’t know how much to make. So
0:22:59 there’s a sort of chicken egg problem. It’s the same thing in book publishing.
0:23:04 So you’ve got the container ship lines that essentially created their own crisis.
0:23:10 They’ve got bigger and bigger ships because that was more efficient for their purposes,
0:23:15 their own costs running ships went down per container as the ships got bigger.
0:23:20 They didn’t devote too much thought to the problems of the ports or the railroads or
0:23:25 the truck lines, and all of them have had a lot of difficulty coping with this flood of containers.
0:23:32 And so I think one question facing this industry going forward is whether these
0:23:36 long-distance supply chains will continue. Well, I have to ask a question though, if that’s,
0:23:41 is that necessarily a disaster because isn’t that also the inevitable sort of cycle of things
0:23:46 aggregating, unaggregating, lengthening and contracting, et cetera. And also in that same
0:23:49 context, one of the arguments I’ve heard for, there’s actually advantages to shorter supply
0:23:54 chains. For example, in the case of hardware and software innovation, there’s this rapid
0:23:59 iteration and back and forth that happens. So if you have a components manufacturer in Mexico
0:24:04 and you’re designing a chip or some piece of hardware, you could rapidly iterate on your designs
0:24:08 without the long delay that happens when you have a big time difference and a bunch of other
0:24:14 logistical issues with someone doing the same thing in China. So there’s some argument that
0:24:18 it’s actually not a bad thing because it actually speedens innovation almost in some cases.
0:24:24 In some cases, it may speed innovation. In general, I think that manufacturers and retailers are
0:24:32 expecting that it’s going to reduce risk. Another trend that you see is that many manufacturers
0:24:39 and retailers are now looking to multiple sourcing. Now, in many industries, it’s cheaper to have
0:24:45 a single source because you’ve got huge economies of scale. One factory makes a ton of stuff,
0:24:49 and that’s great so long as it’s working. It’s cheaper because of the stuff, right?
0:24:56 But maybe it’s worth paying a little bit more and have an extra warehouse. We’re seeing a lot of
0:25:04 that now. We had, for example, a work stoppage out of Los Angeles, actually the West Coast ports
0:25:12 in general, in the early part of the century, a lockout by the port employers. How did that
0:25:15 affect companies? Was it a lockout? You mean like it was like… They locked out the union workers
0:25:21 as part of a labor dispute. Right. And so a lot of companies said, well, maybe we ought to redirect
0:25:30 some of our traffic to ports on the US East Coast. They still send their goods to Los Angeles or
0:25:35 Long Beach or Oakland, but they also send a portion of them now to Savannah or New York
0:25:41 because they want to have options. They want to not have the risk that their supply chain will
0:25:46 be shut down. There’s another fascinating analogy with the digital world here because it reminds
0:25:50 me of the time of the early days of the internet when as internet became super popular and more
0:25:55 multimedia started coming online, there were tremendous bottlenecks in data traveling through
0:26:00 pipes. And so they had to figure out new methods to essentially reroute and decentralize it from
0:26:04 these central choke points. So it’s kind of a fascinating thing. And also now, by the way,
0:26:08 I explained when I was in Panama, I was a little struck by this thing where every single ship that
0:26:13 goes through spends a day being inspected before you can even put it through. And it costs like a
0:26:16 million dollars per ship to put it through or some, I forgot the amount, but it’s some significant
0:26:21 amount. And it just blew my mind like there’s so much extra work. But now I understand because of
0:26:26 one ship bottlenecks, that entire thing, nothing gets through for like the entire day. And that’s
0:26:32 a huge blockage. Yeah, exactly. It’s kind of fascinating. So what we’re seeing in container
0:26:39 shipping now is a lot like what we saw in the United States with the railroads in the 1870s,
0:26:47 1880s, 1890s, when many railroads went bankrupt, we went from a country that had hundreds of railroads
0:26:54 each a few miles long to a relative handful of large railroad networks. We went through
0:27:00 something similar when we had airline deregulation starting in 1978. You may remember we used to
0:27:08 have lots of regional carriers around the country, had had a number of national airlines and only
0:27:13 two international airlines that were heavily protected by the government. Now there’s a lot
0:27:18 more potential competition. And of course, the carriers have dealt with that by merging. So
0:27:23 you’ve actually now got a situation in which you’re supposed to have cutthroat competition,
0:27:28 but they’ve tried to find a way around it by by emerging and reducing the number of airlines.
0:27:32 It’s inevitable cycle. And we’re headed in the same direction with container shipping now.
0:27:38 Many container carriers are in financial distress. A lot of them have merged into the big carriers.
0:27:45 There are now probably three so-called alliances of container carriers that kind of dominate
0:27:52 world trade. So we may be in an environment in which there are few enough players that they’ll
0:27:58 be able to have a better handle on prices, on shipping rates. And that will mean less competition.
0:28:02 That will be good for their shareholders. It probably won’t be good for shippers.
0:28:05 Okay. So the wrap up, we started this with your view that connects the dots between
0:28:12 all these books. And you have this perspective of this economist historian. And the question is,
0:28:16 is it good to know that this is an ordinary economy or are we just talking about cycles of
0:28:20 things that are just going to inevitably decline and grow? How do you know it’s just not a typical
0:28:26 waning and that it’s actually really is something different? I think this actually has a lot of
0:28:33 political implications. For decades and decades, we’ve trained people to believe that the government
0:28:40 can provide a very steady income, can provide low unemployment, can provide rapid economic growth.
0:28:46 And I think the government’s ability to do this is limited. What we’re seeing, I think,
0:28:51 and not just in the United States, is somewhat of a crisis of expectations.
0:28:52 It’s a reckoning.
0:28:58 If you take a look at what’s going on now in Europe or in Korea or in Taiwan, people expect
0:29:04 more of their public officials than their public officials can deliver. People want their incomes
0:29:10 to grow quickly. Their public officials promise, “Yeah, we’ll bring back the good old times. We’ll
0:29:16 make your incomes grow quickly.” But in reality, we’re in a normal age in which people’s living
0:29:21 standards rise slowly. I feel like while you’re saying this, all I can think is like, “Well,
0:29:25 only really time can teach us that that’s not…” Because I’m trying to think, “Well,
0:29:32 what can we do to reset those expectations?” But we can’t, really. It’s just time and not…
0:29:34 Understanding, possibly.
0:29:39 And not having the same growth, right? Getting used to not having the same growth,
0:29:41 which is sort of disheartening when you think about it.
0:29:42 It is on one level.
0:29:44 Because my question is like, “So how did we move beyond that?”
0:29:50 On one level, it’s disheartening. On another level, I think we have trained people to believe
0:29:54 that government can deliver things that really can’t deliver.
0:29:56 So how do we start to undo that?
0:30:02 There is a question about how the available income is distributed, which is really quite
0:30:07 separate from the question of how fast productivity is growing, how fast the economy is growing.
0:30:14 And I think we have to have a real discussion about how income is being distributed and how
0:30:16 automation is going to affect our workforce.
0:30:20 This is a time of mine for everybody, including us, guests, everybody.
0:30:26 And I bring this up not really in an economic sense, but almost more in a psychological sense.
0:30:31 There’s a lot of concern about where the jobs are going to be for people in the future.
0:30:32 I’m not too concerned about that.
0:30:36 I’m pretty confident that we’ll have ways in which people can earn livings.
0:30:44 But so many people get some degree of satisfaction from their work.
0:30:51 And if what we’ve got is a world in which people are doing part-time work, occasional work,
0:30:52 unsteady work…
0:30:53 I mean, work itself has become containerized.
0:30:59 That’s right. What are people going to be moored to in this sense?
0:31:05 And we can do anything we want to guarantee your income.
0:31:10 But the fact is, if all you do is wake up in the morning and watch television,
0:31:14 because you’ve got nothing else to do, you’re not going to be very happy.
0:31:21 So I think we have an issue here that really goes beyond economics to finding meaning in
0:31:22 our lives as human beings.
0:31:23 To the human condition.
0:31:25 One last thing.
0:31:27 You talk about a crisis of expectation.
0:31:30 But the reality, and this is actually another theme that connects the dots,
0:31:32 is that these problems are multifactorial, multimodal.
0:31:34 There’s crisis of expectations around the world.
0:31:39 And they’re playing out in ripples and waves and different ways across France, Europe,
0:31:41 the US, and so many different ways.
0:31:46 So I also wonder if there’s some change in the geographic or
0:31:48 governance structures that we have to think about.
0:31:51 Do you have any thoughts on the geopolitical implications of this?
0:31:53 There’s any last parting thought on that front?
0:32:00 We’ve seen, obviously, a big shift away from faith in the nation state
0:32:05 to people wanting power and control closer to home.
0:32:10 I think we’ve seen over the centuries cycles in that, that sort of comes and goes.
0:32:17 Will city governments be able to deliver satisfaction in a way that national governments can?
0:32:20 I’m not convinced of that.
0:32:27 But in some issues, some areas related to people’s quality of life, they can be very important.
0:32:36 I think another issue that we face is that there are things we know that will improve
0:32:43 productivity over time. We can’t predict how that’ll work, and we still need to make those
0:32:50 expenditures. So, for example, we know that improving education levels is in general good for
0:32:57 countries’ productivity. So we need to invest in education, but can we say if we spend an extra
0:33:01 billion dollars in education now that it will improve productivity three years from now?
0:33:03 We can’t say that. We’re doing this somewhat on faith.
0:33:05 Especially if the skills and jobs of the future change.
0:33:12 Well, that’s correct. We know that as a general proposition, it’s been important for economic
0:33:18 growth that we’ve had scientific research going on. Does that mean that if we put more money into
0:33:24 scientific research now that we will be able to benefit from the consequences at any predictable
0:33:26 time in the future? The answer to that is no.
0:33:29 Right. And these are the reasons exactly why we tend not to make these decisions.
0:33:33 That’s exactly right. That’s exactly right. These are very tough choices because you’re asking for
0:33:38 our tax money to be spent, and you really can’t promise the return.
0:33:41 It’s like investing in the future. Difficult to do.
0:33:44 Well, Mark, thank you for joining the A6NZ podcast.
0:33:47 Thank you so much for having me. It’s been great fun.
0:33:47 Thank you.
0:33:57 Thank you.
This podcast rerun — first recorded over two and a half years ago, now being rerun as one of our evergreen classics on the tails of the world’s largest designated shopping days (Black Friday, Singles Day in China, Prime Day online, and so on) — is ALL about the container ship. Also known as “The Box“, with author Marc Levinson (in conversation with Sonal Chokshi and Hanne Tidnam). But this episode is really about connecting the dots between logistics, transportation, infrastructure, and much more.
What do we make of the so-called “death of retail”, especially when seen through the retail history of the once-largest retailer in the world? How are supply chains changing today? One thing’s for sure: the shipping container made the world much smaller… and the world much economy bigger.
image: Kevin Talec / Flickr
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Nursing Today, From the Bedside and Beyond
AI transcript
0:00:03 The content here is for informational purposes only,
0:00:05 should not be taken as legal business tax
0:00:06 or investment advice,
0:00:09 or be used to evaluate any investment or security
0:00:11 and is not directed at any investors
0:00:14 or potential investors in any A16Z fund.
0:00:18 For more details, please see a16z.com/disclosures.
0:00:21 – Hi, and welcome to the A16Z podcast, I’m Hannah.
0:00:23 For many of us, nurses are essentially
0:00:25 the face of the healthcare system.
0:00:27 The person you’ll see the most of while you’re in it,
0:00:30 who will monitor your vitals, administer medications,
0:00:32 hold your hand when you’re in pain or scared,
0:00:35 answer all the questions you forgot to ask the doctor.
0:00:37 In this episode, we talk all about the role
0:00:40 of that unsung hero of the healthcare system, the nurse.
0:00:44 Iman Abouzade, CEO and co-founder of Incredible Health,
0:00:45 a hiring platform for nurses,
0:00:49 and A16Z general partners Jeff Jordan and Julie Yu
0:00:50 on the consumer and bio teams,
0:00:52 discuss with Hannah Tidnam
0:00:55 how the scope of the job is changing today and why,
0:00:58 what’s driving the looming nursing labor crisis
0:01:00 and all the ways we might be able to impact that,
0:01:01 what it’s like to build
0:01:03 an innovative marketplace platform in healthcare
0:01:05 and how best to introduce innovation
0:01:08 into the healthcare system overall.
0:01:09 So we’re here today to talk about
0:01:10 the role of the healthcare worker
0:01:12 and specifically the role of the nurse.
0:01:15 We’ve all of us, I’m sure, interacted with nurses.
0:01:16 I think we have a sense of what the job looks like
0:01:18 when you’re there in the doctor’s office,
0:01:19 but can we zoom out a little bit
0:01:21 and talk about what the job looks like
0:01:22 from an industry level?
0:01:24 – So there’s a lot of clinical workers in healthcare
0:01:27 and it’s a very labor intensive industry.
0:01:30 And so as of say like 2018,
0:01:32 I became the biggest industry in the US
0:01:34 in terms of number of workers.
0:01:36 And it’s a very labor intensive industry.
0:01:39 So the majority of those workers are nurses.
0:01:41 So 60% of clinical workers are nurses.
0:01:43 – Oh my gosh, that’s a really high percentage.
0:01:44 – It’s a really high percentage.
0:01:46 – How many nurses are there in the United States?
0:01:48 – So there’s 3 million nurses in the US.
0:01:50 – That’s like 1% of the US population.
0:01:51 – And when you say labor intensive,
0:01:54 do you mean physically labor intensive or ours?
0:01:55 What do you actually mean by that?
0:01:56 – What I mean by labor intensive
0:01:58 is you need a lot of workers to deliver the care
0:02:01 in the same way a restaurant is labor intensive.
0:02:02 There are team players,
0:02:04 they’re involved when patients are entering
0:02:06 the hospital or healthcare facility
0:02:09 during their entire stay and also during discharge.
0:02:12 They make a huge impact on the patient’s experience
0:02:13 while they’re in the facility.
0:02:14 – Nurses are kind of the engine
0:02:16 of how hospitals and clinics work.
0:02:19 When you think about an encounter as a patient,
0:02:22 the number of minutes that you spend sort of interfacing
0:02:23 with any of the healthcare workers,
0:02:24 the vast majority of those minutes
0:02:25 are likely to be with the nurse.
0:02:28 It’s on admission, even the upfront triage,
0:02:30 when you get referred to a facility,
0:02:33 oftentimes that first point of contact
0:02:34 where they are trying to qualify,
0:02:36 where in the hospital should I even send you,
0:02:38 sometimes is a nurse.
0:02:41 Because of the need to actually clinically understand
0:02:42 what is happening to you as a patient.
0:02:45 The doctor is typically kind of the primary type
0:02:47 of provider that one thinks about
0:02:49 when interacting with the healthcare system,
0:02:51 but oftentimes the physician is actually the one
0:02:52 that you spend the least time with
0:02:54 in a healthcare encounter vis-a-vis a nurse.
0:02:56 – That’s right, yeah.
0:02:58 – So when you say labor intensive,
0:02:59 what does that actually break down to?
0:03:01 How many patients for how many nurses?
0:03:03 – Yeah, it’s funny you bring that up
0:03:05 because that’s a really controversial topic.
0:03:07 The topic of staffing ratios,
0:03:09 how many patients to a nurse.
0:03:11 So in the state of California, it’s actually regulated
0:03:15 and it’s five patients to one nurse at any given time.
0:03:16 It’ll vary by unit.
0:03:18 So for example, in the intensive care unit,
0:03:19 it’s more like two patients to one nurse.
0:03:21 But California is one of those rare states
0:03:24 that we’re just a little bit more regulated here.
0:03:26 Now there are nurses all over the country
0:03:27 fighting for staffing ratios
0:03:31 because when you have too many patients to one nurse,
0:03:34 your quality of care goes down, nurses get burnt out.
0:03:37 A nurse who’s working beyond the 12 hour shift, right?
0:03:39 They’re on hour 15, 16.
0:03:41 The research shows they are 2.5 times more likely
0:03:43 to create a medication error.
0:03:45 There’s also research that shows when you’re understaffed,
0:03:47 your patient mortality goes up by 4%, right?
0:03:49 So the patients are literally more likely to die
0:03:51 when the hospital’s understaffed.
0:03:52 It’s a really challenging problem.
0:03:54 – And that’s not regulated as well.
0:03:56 It seems like if you’re regulating the ratios,
0:03:58 like you would not be regulating the–
0:03:59 – It should be, but you know.
0:04:01 – They relate truckers, but not nurses.
0:04:04 – So let’s actually talk about the scope of the job.
0:04:05 What does that look like today?
0:04:07 The job is changing in clinical terms.
0:04:08 Is it also changing in other ways?
0:04:11 – There’s increasingly more and more administrative work
0:04:14 to be done just because of the way hospitals bill
0:04:16 and the way medical records work
0:04:18 that things have to get recorded.
0:04:21 So also for a bunch of liability and malpractice reasons,
0:04:23 you also have to record everything.
0:04:24 And so the nurses heavily involve
0:04:25 in documentation as well.
0:04:27 – Which also involves reimbursement.
0:04:28 They’re a pretty core function
0:04:30 for both the patient and the provider.
0:04:31 – And anything reimbursement related,
0:04:33 oftentimes that’s viewed as something
0:04:35 that is sort of below the pay grade of the physician.
0:04:37 Health plans and insurance companies oftentimes
0:04:39 are employing droves of nurses
0:04:41 for things like prior authorization
0:04:44 and sort of medical necessity assessment
0:04:46 because you do need to literally review
0:04:48 and actually notes around that patient encounter
0:04:49 to determine whether or not
0:04:51 it is something that should be reimbursed
0:04:53 under those medical circumstances.
0:04:55 And right now there’s not a great way
0:04:57 to sort of automate that process.
0:04:58 And so it does require human judgment.
0:05:00 And oftentimes, again, those folks are nurses
0:05:02 because it’s expensive to do it with a nurse,
0:05:04 but it’s even more expensive to do it with a physician.
0:05:07 And so it’s sort of the lowest sort of level of clinician
0:05:09 that you can still have that judgment,
0:05:12 but do it in as cost-effective of a way as possible.
0:05:14 – So we’re in the middle of a big nursing shortage.
0:05:17 There’s been a lot of coverage about this looming crisis
0:05:20 in nursing, and I understand the regulation to make it
0:05:23 so that nurses aren’t handling 25 patients at one.
0:05:26 But why are nurses in such short supply?
0:05:28 – Our demand for healthcare as a country keeps going up
0:05:30 as our population ages,
0:05:32 growing demand, not enough supply of workers.
0:05:35 The nursing shortage is a number one skilled labor shortage
0:05:36 we have in this country.
0:05:38 And it’s estimated that by 2024,
0:05:40 we’ll be one million nurses short.
0:05:43 – The shortage of workers is estimated to be three times
0:05:46 larger than the shortage of engineers in the United States.
0:05:48 So I mean, these are big, big numbers.
0:05:49 – Are there other reasons as well,
0:05:51 besides just the growing system?
0:05:53 Are there things specific to the job
0:05:56 that people are not bringing in more talent?
0:05:58 – The other reasons that kind of just exacerbate
0:05:59 the situation is one,
0:06:02 nursing schools are not able to take in as many students
0:06:06 as they would like because their faculty is also retiring.
0:06:08 You know, the biggest group of nurses right now
0:06:10 is millennials, but the second biggest is the baby boomers.
0:06:12 So it’s expected that 20% of nurses
0:06:14 are expected to retire in the next three years.
0:06:17 And that includes not just the nurses on the floor
0:06:19 or in the units, but also the nurses
0:06:21 who train other nurses in nursing schools.
0:06:23 So there’s also a shortage of faculty too.
0:06:25 – There’s also geographic mismatches
0:06:28 where they’re acute shortages in certain places.
0:06:30 – But it’s prevalent throughout.
0:06:31 So even in all the big cities,
0:06:34 whether it’s New York City, LA, San Francisco,
0:06:36 they are all suffering from shortages.
0:06:39 – So does that mean it’s a good career to get into
0:06:40 because you’re highly desirable?
0:06:42 – It is an amazing career to get into.
0:06:45 For job security, it also pays quite well.
0:06:47 And because of the labor shortage,
0:06:49 the compensation does keep moving up.
0:06:52 So for example, in California specifically,
0:06:56 the average salary for a nurse is $100,000.
0:06:59 In the Bay Area, it’s closer to $140,000.
0:07:02 In LA, the average is $120,000.
0:07:04 It has traditionally been looked at as a blue collar job,
0:07:06 but they’re getting white collar compensation now.
0:07:08 And it does require a degree.
0:07:11 It does require training and certifications.
0:07:15 So you have OR nurses, ICU nurses, emergency nurses,
0:07:18 oncology nurses, with more expertise,
0:07:20 with more certifications, with more training
0:07:21 in specific areas.
0:07:24 So I think there’s a perception that it’s blue collar,
0:07:24 but it’s actually not.
0:07:26 – I mean, it’s a pretty rigorous curriculum
0:07:29 with certifications and tests and things like that.
0:07:30 I’ve talked to a number of young people
0:07:32 who are considering a career in nursing
0:07:34 and they’re like, I know it’s gonna be hard work.
0:07:36 I know it’s gonna take a long time,
0:07:38 but the prize at the end is rewarding.
0:07:40 – Actually, what does that look like?
0:07:42 How much education, how much certification?
0:07:45 – Yeah, so the usual degrees are either the BSN,
0:07:46 Bachelor of Science in Nursing,
0:07:48 or the Associate’s Degree in Nursing.
0:07:50 The Associate’s Degree is kind of falling out of favor
0:07:53 as hospitals increasingly require a bachelor’s degree.
0:07:56 And then even after the degree, you start working,
0:07:58 but you are also training and/or specializing
0:07:59 in specific units as well.
0:08:01 – And is that degree falling out of favor
0:08:03 because nurses are doing more and hospitals want nurses
0:08:05 with a higher degree of education?
0:08:06 – Yeah, you just stumbled on another
0:08:09 really controversial topic.
0:08:12 There’s a certification for hospitals called MAGNIT,
0:08:15 and one of the requirements to be MAGNIT certified
0:08:16 as a hospital is to have, you know,
0:08:19 the majority of your nurses with bachelor’s degrees.
0:08:21 So like many, many things in healthcare
0:08:22 because it’s a regulated profession
0:08:25 and a regulated industry, but it’s also an industry
0:08:27 that they’re very big on brands
0:08:30 and it’s yet another stamp that a hospital
0:08:31 or an academic medical center can get.
0:08:33 – Okay, so the hospitals are getting squeezed
0:08:36 by the regulation and then also by this increasing demand
0:08:38 for a certain level of expertise.
0:08:40 And the nurse’s job is growing.
0:08:42 What is the bottom line for hospitals at the moment?
0:08:45 How are they dealing with this kind of increased pressure?
0:08:46 – Yeah, so here’s the bottom line.
0:08:50 When you’re understaffed or when you don’t have enough nurses,
0:08:54 you end up spending on overtime, on contract workers,
0:08:55 and you can’t see as many patients.
0:08:57 So this whole issue that–
0:08:58 – So higher costs and lower revenue.
0:08:59 – Exactly.
0:09:00 – Other than that, not an issue.
0:09:03 – Exactly, higher costs and less revenue.
0:09:06 And it is probably the number one issue
0:09:08 for hospital executives, staffing is,
0:09:10 and it’s definitely certainly their number one cost.
0:09:13 And the thing to keep in mind is that hospitals
0:09:15 are thin margin businesses.
0:09:17 The average margins is 3%.
0:09:19 – That’s interesting because I think the common perception
0:09:21 is that hospitals tend to be places
0:09:23 with huge high volume financial flow.
0:09:24 – Cost structures are so high
0:09:27 that it’s hard to operate in the black.
0:09:28 I mean, the other thing that’s contributing
0:09:30 to a lot of this is, you know,
0:09:32 we talk a lot about the unbundling of the hospital
0:09:33 and the fact that a lot of the care
0:09:35 that used to require coming to a hospital
0:09:38 is now being provided sort of out of the communities
0:09:41 in urgent care clinics and, you know, retail type settings.
0:09:44 And many of those clinics are actually staffed by nurses.
0:09:46 And so, you know, at the same time
0:09:47 as you have these shortages,
0:09:49 sort of in the traditional care settings,
0:09:51 you also have more demand coming
0:09:53 from these sort of alternative sites of care
0:09:55 that are designed specifically to be staffed
0:09:58 by lower acuity providers, not physicians.
0:10:00 And the whole purpose of those care settings
0:10:03 is to reduce costs on the delivery side.
0:10:05 But it’s just this sort of vicious cycle
0:10:07 where that’s also contributing to higher demand
0:10:08 for this kind of skill set.
0:10:10 – What does that process look like today
0:10:12 for the profession of finding the right job,
0:10:14 you know, the right hospital, the right clinic?
0:10:16 – Yeah, it’s pretty broken right now.
0:10:19 So if you’re looking for a job, for example, as a nurse,
0:10:23 you have to apply to probably 10, 15, 20 places.
0:10:25 And most of the time you don’t even hear back.
0:10:26 And if you hear back, it could take months.
0:10:28 – But why, if they need them so badly,
0:10:29 I don’t understand, it seems so.
0:10:32 – So we talked a lot about the shortage and the under supply,
0:10:34 but the other thing that kind of plagues
0:10:35 this industry is inefficiency.
0:10:38 And the talent acquisition teams or HR teams
0:10:40 inside hospitals are armed
0:10:42 with pretty outdated tools and processes
0:10:45 that really haven’t changed since like the 90s.
0:10:48 And they’re primarily using external job boards
0:10:51 like Indeed or LinkedIn or their own hospitals job board,
0:10:53 put a posting out there and hope something happens.
0:10:55 That’s really difficult when you are going after
0:10:57 a group of workers that are in high, high demand.
0:10:59 And so you’re basically waiting
0:11:00 for the right people to come.
0:11:02 And it’s really quantity over quality.
0:11:06 So when people apply, the HR teams are manually sifting
0:11:07 through all of those applicants
0:11:10 and manually matching them as well.
0:11:13 And so that just creates an insane amount of inefficiency.
0:11:15 At any given time, one hospital recruiter
0:11:16 is trying to fill a hundred jobs.
0:11:18 – Another contributor to inefficiencies
0:11:21 on the health system side are really when patients come in,
0:11:24 how do you sort of effectively match demand to supply?
0:11:27 And today that’s done in a barely brute force way,
0:11:30 there really aren’t technology tools with intelligence
0:11:33 that allow you to route and triage patients
0:11:36 to the right type of provider or the right type of nurse
0:11:38 or even distinguish whether or not a patient
0:11:41 is appropriate to see a nurse versus a doctor.
0:11:43 And that’s one of the highly evolving areas
0:11:47 of the market right now is the scope of practice concept
0:11:51 where things that maybe used to be only possible
0:11:53 to do by a physician, increasingly
0:11:55 those boundaries are being redrawn
0:11:57 and nurses are taking on a lot more of that.
0:12:00 But that’s not yet reflected in sort of that routing logic,
0:12:01 so to speak.
0:12:03 And so you often will end up with situations
0:12:06 where a patient will end up waiting eight weeks
0:12:07 to see a physician when in fact,
0:12:09 that person likely could have gotten in
0:12:10 to see a nurse much sooner.
0:12:13 And that has not only clinical implications,
0:12:14 obviously for the patient,
0:12:16 but operational inefficiency implications
0:12:18 for the physicians in the hospital system
0:12:21 where that doctor is not being effectively utilized
0:12:22 for their unique expertise
0:12:25 versus a lower sort of acuity provider.
0:12:26 And then for the health system,
0:12:27 they’re losing out on potential revenue
0:12:29 if again, if those slots are not being fully utilized
0:12:30 to their full extent.
0:12:31 – I just had this happen to me last week.
0:12:33 My doctor was unavailable for two weeks
0:12:36 and then the nurse practitioner would see me the same day.
0:12:37 – Yeah, and there are real sort of societal
0:12:39 and cultural challenges with that.
0:12:42 I think Americans are not yet fully bought into
0:12:44 sort of going to a nurse for something
0:12:46 that they think they should go to see a doctor about.
0:12:47 And we hear that all the time in the market.
0:12:49 In fact, it might be better to go to a nurse
0:12:51 for certain things because you are gonna get
0:12:52 a different level of empathy,
0:12:55 a different level of care and support and service.
0:12:56 And so that’s also contributing to this,
0:12:58 but that’s sort of the notion
0:13:01 of the most effective use of clinical resource.
0:13:03 I think it’s a big component of the challenge here.
0:13:05 – The process is largely on the same way
0:13:07 it was a generation ago.
0:13:08 It’s a paper oriented process
0:13:10 because the tech tools don’t really work
0:13:13 for something this specialized and this unique.
0:13:15 So, you know, the dominant job platforms
0:13:18 are LinkedIn and Indeed and Zip Recruiter,
0:13:21 but they’re not engineered to have this level
0:13:23 of specificity and this granular of matching.
0:13:25 You know, they’re not checking licenses
0:13:27 and credentials and certifications
0:13:31 and aren’t set to match those with existing job openings
0:13:33 ’cause the horizontal platforms kind of fall prey
0:13:35 to the least common denominator factor.
0:13:37 – Can you explain a little bit more about what you mean
0:13:40 by that, Jeff, that the horizontal platforms fall prey
0:13:41 to the least common denominator?
0:13:44 – If you’re trying to fill everything from a CEO
0:13:47 to a sales rep to, you know, oncology nurse,
0:13:49 you’re not going to have the same certifications
0:13:50 clearly for the CEO.
0:13:54 For the nursing and that general purpose tool
0:13:57 does not work well for that highly specialized vertical.
0:14:00 We see a natural progression that tends to repeat over
0:14:03 and over where, you know, the one horizontal platform
0:14:05 serves the needs of multiple verticals.
0:14:08 eBay, you know, started as trading collectibles,
0:14:10 but then they added computers and sporting goods
0:14:12 and clothes and, you know, and cars.
0:14:14 We even sold an airplane when I was there at Gulfstream.
0:14:18 And so the same platform is being called, in this case,
0:14:21 to service all the needs of that vertical.
0:14:23 And early on in platform development,
0:14:26 that typically is sufficient because it’s so much better
0:14:28 than the analog alternative.
0:14:31 But as these platform gets big and the individual verticals
0:14:34 on that platform get big, there’s an opportunity
0:14:37 for new codes to come in and better serve the needs
0:14:41 of that vertical relative to the one size fits all.
0:14:45 For example, StubHub came along and did a highly tailored
0:14:48 offering for the resell of secondary tickets.
0:14:52 They had time and energy and site space to do things
0:14:54 like ensure electronic delivery of tickets, you know,
0:14:57 have a trust and safety function for if the ticket
0:14:59 didn’t work when you got to the venue.
0:15:03 And as a result, StubHub was able to build a big business
0:15:06 in the secondary ticket market, taking a lot of that business
0:15:06 away from eBay.
0:15:10 Right now, StockX are doing collectible sneakers.
0:15:13 You know, Poshmark is doing apparel and each of those
0:15:17 is building verticals that in some cases taking one
0:15:18 of their verticals and doing it better.
0:15:21 – So what do we need to see then if we’re to better serve
0:15:23 the needs of the specific vertical?
0:15:25 – To be honest, most healthcare workers are not on LinkedIn.
0:15:27 And then so that makes the search and discovery
0:15:29 for the employers very difficult.
0:15:31 And the search and discovery fields, you know,
0:15:33 they’re not healthcare specific either.
0:15:36 And then you have the in-mail product that the response rates,
0:15:38 like it’s less than 10% the response rate on in-mail.
0:15:40 So there’s a lot of improvement needed.
0:15:43 – So high signal is better than low signal.
0:15:44 – Yeah.
0:15:47 – So now you’re in a narrow vertical one job description
0:15:51 and the complexity and optionality is enormous.
0:15:54 How could that horizontal platform begin to address it
0:15:58 if it’s highly challenged in a highly constrained environment
0:15:59 to address it really well?
0:16:02 So I mean, that’s a lot of the thesis is it takes that level
0:16:06 of focus specialization, maniacal optimization
0:16:09 to add value to the healthcare system
0:16:13 and to the nurses that helps bridge the gap.
0:16:15 – So if now is the moment for the healthcare vertical
0:16:17 to kind of be better addressed,
0:16:20 what does that actually look like in tactical detail?
0:16:21 – We’ve done three or four things
0:16:23 that are specific for this industry.
0:16:26 Number one is that the employers apply to the talent
0:16:27 instead of the other way around.
0:16:29 We get away with that because there’s such a big shortage
0:16:31 and honestly, that’s what’s needed
0:16:33 given the supply, demand and balance in this market.
0:16:36 The second thing is we’ve largely automated the screening
0:16:38 things like licenses and certifications
0:16:40 and experience and skills.
0:16:42 All of these things that the hospital usually does manually
0:16:44 by using technology, you can just deliver
0:16:47 a lot higher quantity and quality of talent to the employers.
0:16:50 – A highly curated sample based on their specific need.
0:16:51 – Exactly.
0:16:53 And so then the third piece is the custom matching, right?
0:16:56 So it is not helpful for a recruiter
0:16:59 to log into their web application and see 200 candidates.
0:17:02 They need to just see the 12 out of the best fit.
0:17:04 – Right, no, 200 just makes you want to close it again.
0:17:04 Do something else.
0:17:06 – Think of the gains the hospitals.
0:17:08 If you all of a sudden, the process goes
0:17:12 from a torrent of inbound to highly curated sample.
0:17:15 The number of resumes you review goes way down.
0:17:18 The number of interviews you do typically goes way down.
0:17:20 The time to hire goes way down
0:17:22 because you’ve got that curated sample
0:17:26 of qualified nurses for this specific position you have.
0:17:29 You are creating a very high level of operational efficiency
0:17:31 for the administrator at the hospital
0:17:33 and that administrator is very, very busy.
0:17:34 – And it’s the same experience on the talent.
0:17:37 The nurse does not want to hear from 80 employers.
0:17:39 They want to hear from the three that are the right fit.
0:17:41 And so building those custom matching algorithms
0:17:42 are really important.
0:17:45 Dry the experience and the efficiency for both sides as well.
0:17:46 And then the fourth piece,
0:17:50 we provide pretty robust data analytics to the employers
0:17:52 where they can see their utilization
0:17:54 and their hiring process
0:17:55 and they have a lot more visibility into it.
0:17:57 And they can even see the number of days talent
0:17:59 is spending between each step.
0:18:01 And they’re able to benchmark that against their competitors
0:18:04 ’cause their competitors are also using our platform.
0:18:06 – So just shining a light on that kind of black box
0:18:09 where things would languish in weird limboes
0:18:10 for a super long time.
0:18:12 I mean, just like any industry, any function,
0:18:14 a lot of decisions should be based on data.
0:18:17 And HR and talent acquisition is a function
0:18:20 that has an insane amount of data,
0:18:22 but sometimes it’s hard to get at.
0:18:24 And that’s what decisions should be based on,
0:18:26 how they can improve their internal hiring processes.
0:18:27 – Can you talk a little bit about
0:18:29 how this actually affects the bottom line
0:18:30 of hospitals and providers?
0:18:32 Like how does making a specific search field
0:18:35 for certification actually turn into dollars saved?
0:18:37 – Hospitals and health systems are able to hire
0:18:40 and fill those roles for permanent nurses
0:18:41 in less than 30 days,
0:18:43 where that national average is 90 days or longer.
0:18:45 That results in significant,
0:18:47 like millions of dollars in cost savings for the hospital,
0:18:49 because they’re not spending on overtime,
0:18:51 they’re not spending on contract workers.
0:18:53 – And healthcare is notorious for it being
0:18:55 a very, very challenging place for technology companies
0:18:56 to prove ROI.
0:18:57 And this is one of those areas
0:19:00 where there’s such a clear top line benefit
0:19:02 because you can literally say my patient volumes
0:19:05 are hurt or benefit from being able
0:19:06 to hire nurses more quickly.
0:19:07 – And hire revenue.
0:19:10 – Because you have the capacity to take
0:19:11 on the business you need.
0:19:13 – The other place where the revenue piece shows up
0:19:14 is just in terms of patient access.
0:19:16 You know, one of the crises in this country
0:19:19 is the fact that patients cannot access care
0:19:20 because of these supply constraints.
0:19:23 It goes back to this notion of kind of right sizing care.
0:19:26 If you were a patient who had, let’s say, elevated PSA,
0:19:29 that is a fairly wide spectrum of clinical,
0:19:31 you know, may actually warrant going straight
0:19:34 to a urologist versus you might have to be worked up
0:19:36 and kind of go through a care journey.
0:19:37 But if you were not doing this appropriately,
0:19:40 you would essentially be sort of closing the door
0:19:42 to patients because you were making them wait.
0:19:43 The patient wouldn’t get the clinical benefit
0:19:45 and then you were losing out on that revenue stream.
0:19:47 And frankly, the physicians, you know,
0:19:50 they would always say I’m optimizing for surgical yield.
0:19:53 I want a mix of patients who are most likely
0:19:56 to result in a case that is gonna take advantage
0:19:57 of my unique skill set.
0:20:00 And so even from a physician retention, satisfaction,
0:20:02 et cetera, that perspective,
0:20:03 that was a huge issue
0:20:05 that these organizations were trying to deal with.
0:20:08 – Did nurses get to optimize for anything like that as well?
0:20:09 – Oh, absolutely.
0:20:11 No, I mean, it’s the same thing where I think for nurses
0:20:13 and even MAs and some of these other, you know,
0:20:15 types of roles that have sort of popped up
0:20:18 to kind of support the administrative overhead,
0:20:21 you started to see, again, the administrative tasks
0:20:23 be passed on to these folks
0:20:26 who are very legitimately trained in clinical practice.
0:20:29 And we’re taking on these sort of lower utility tasks.
0:20:31 How can technology sort of effectively route people
0:20:33 so that some of that burden disappears?
0:20:36 – So when you’re creating a jobs marketplace like this
0:20:38 where you’re matching up this highly vetted,
0:20:41 highly curated with all these different requirements
0:20:44 and challenges from regulation and certification,
0:20:47 how do you think about vetting for the non-obvious stuff?
0:20:50 Like about empathy, about bedside manner,
0:20:51 how do you think about those?
0:20:52 – That stuff is really important
0:20:55 ’cause ultimately the mission of most of these hospitals,
0:20:58 all of them probably, is to deliver amazing care, right?
0:21:01 And putting all the hard skills aside,
0:21:03 the licenses, the certifications, all the hard skills.
0:21:05 There is a whole set of soft skills
0:21:07 that people need to convey and practice
0:21:09 when they’re on the floor as well.
0:21:12 We have an entire interview preparation kind of like module,
0:21:14 basically that helps nurses convey
0:21:16 their softer skills and interviews.
0:21:17 What are they motivated by?
0:21:20 Are they truly motivated by patient care or not?
0:21:22 How much empathy do they have?
0:21:23 What are their motivations?
0:21:25 What do they want to do with their career?
0:21:27 We’ve taken a much more like hands-on approach
0:21:28 with just like, hey, these are the things
0:21:31 that you need to just really convey in your interview.
0:21:32 – What was the most challenging thing
0:21:33 for you to build into the system
0:21:35 when you’re building these tools from the ground up?
0:21:39 – I think the challenge of just the heterogeneity of this,
0:21:42 like so we’re dealing with all RNs and NPs.
0:21:46 There’s multiple specialties and multiple requirements.
0:21:48 And then the employers also have lots of different needs.
0:21:50 And when you’re trying to build technology
0:21:53 that works for that, for all the users, it’s challenging.
0:21:55 – The healthcare industry is notoriously difficult
0:21:57 to disrupt with new innovation,
0:21:58 often for very good reason.
0:22:01 And because of the complex nature of the system itself,
0:22:04 how do you see yourself fitting into an overall trend
0:22:07 of new technological innovation in healthcare?
0:22:09 Or I guess another way to say that is,
0:22:11 what has your experience been like
0:22:14 introducing a new tech into this particular system?
0:22:15 – I actually feel a lot of empathy
0:22:17 for some of the hospital executives
0:22:19 and the administrators and the nurse managers
0:22:22 and so on who are trying to manage the operations, right?
0:22:24 Internally, they’re dealing with multiple issues
0:22:25 at the same time.
0:22:27 First of all, like reimbursements going down, right?
0:22:29 So they had a lot of revenue pressure.
0:22:32 Number two, it’s actually not completely clear
0:22:33 in the healthcare industry or in a hospital
0:22:35 who your actual customer is.
0:22:37 Common sense would say it’s just the patient,
0:22:40 but the patient doesn’t actually, for the most part,
0:22:42 doesn’t pay for the care directly, right?
0:22:45 So they also have to take into account health insurance,
0:22:47 the payers, how they’re ultimately making money
0:22:48 and how they’re getting reimbursed.
0:22:50 So that’s why you see a lot of the technology investments
0:22:53 in healthcare or in a hospital are more around billing
0:22:56 than around optimizing operations, right?
0:22:59 And then you also have employers in the healthcare industry
0:23:01 who are ultimately also the ones who are paying for the care.
0:23:04 And their employers are offering the health insurance
0:23:07 to the employees and they’re making decisions
0:23:09 about what plans to offer
0:23:11 and there’s not much clarity on pricing.
0:23:13 It’s just like a very convoluted industry, right?
0:23:17 Where just like the normal free market forces
0:23:19 and competition that we see in other industry
0:23:21 doesn’t necessarily apply.
0:23:23 – The stakes are just so much higher
0:23:24 than any other industry.
0:23:25 If you turn an engineer,
0:23:26 you’re probably gonna lose a little bit on productivity
0:23:28 and maybe not ship some code.
0:23:31 But here, if you are constantly churning talent
0:23:34 and turning over folks who are staffed in these environments,
0:23:36 there is such huge risk
0:23:37 from a patient safety perspective on that
0:23:40 because these teams have protocols
0:23:42 and they have ways that they respond
0:23:44 to sort of emergency situations and whatnot
0:23:46 to train and really sort of get up to speed
0:23:48 on those types of environments,
0:23:50 very complex environments takes time.
0:23:52 If you’re not doing that match upfront
0:23:54 in a way that sort of guarantees
0:23:56 or at least raises the probability
0:23:58 of longer retention of these employees,
0:24:01 then there’s a real high stakes risk to patients.
0:24:04 – Actually, let’s talk about that retention piece specifically.
0:24:06 We’ve talked about the talent acquisition,
0:24:08 but not so much how do you hold on to good talent?
0:24:11 What’s the turnover rate like in this profession?
0:24:15 – The annual turnover for nurses in the US today is 20%.
0:24:17 – Oh my gosh, is that because it’s so hard
0:24:19 or because people move or what?
0:24:21 – The number one driver is understaffing, right?
0:24:22 ‘Cause when you’re understaffed,
0:24:24 you’re burning out your existing workers.
0:24:26 And then also it’s a really tight labor market.
0:24:28 You tend to change jobs more often when there’s a shortage.
0:24:29 – So what happens?
0:24:31 You get the job and then you’re overworked
0:24:33 and you start to become disillusioned
0:24:34 and then you think you’re gonna have
0:24:36 a better job elsewhere essentially?
0:24:37 – Yeah, there’s probably three or four main factors
0:24:39 why nurses change jobs.
0:24:41 Number one is like, they’re tired and burnt out
0:24:42 and just need a different unit
0:24:44 or hope for a hospital that’s better managed
0:24:45 or better staffed.
0:24:47 Number two is they’re trying to reduce commute times.
0:24:49 90% of nurses are women.
0:24:51 Many of them are taking care of children.
0:24:53 Many of them are trying to shorten commute times.
0:24:55 – I can’t believe it, it’s 90% still, that’s so high.
0:24:56 – Yeah, it’s still high.
0:24:59 And then career advancement is another reason.
0:25:00 So if you’re trying to grow your skill set,
0:25:02 become more specialized and you’re not seeing those
0:25:03 opportunities with your current employer,
0:25:05 you’re gonna change and then higher pay.
0:25:07 – As good market wages ’cause it’s applied
0:25:08 to man in balance.
0:25:10 – It’s funny, it sounds like all the normal reasons,
0:25:11 but like super condensed into like a,
0:25:14 where you feel them very acutely and it happens very fast.
0:25:17 Okay, so on retention, what are the things
0:25:20 that people can do then besides finding the right job
0:25:24 the first time and supplementing the supply
0:25:26 so that there is not a critical shortage
0:25:29 and you’re working way long hours?
0:25:31 What are other things that employers and hospitals
0:25:33 can do to solve that piece of the problem?
0:25:36 – The few factors that influence it and the hospitals
0:25:39 that have the best retention do this extremely well.
0:25:41 Number one is fast hiring.
0:25:43 So it turns out if you have an amazing candidate experience
0:25:45 while you’re getting hired, you are more likely
0:25:46 to stay around.
0:25:47 – Really?
0:25:49 Even if you get disillusioned a little bit later?
0:25:51 – Yeah, because that’s part of it.
0:25:52 – Even disillusioned before you start,
0:25:55 that’s usually not a good leading indicator.
0:25:57 – That’s true, that’s true.
0:26:00 If you’re hired in 11 days, you have a very positive
0:26:01 impression of that employer, like oh my goodness,
0:26:03 like they have their act together.
0:26:06 And then that leads to higher employee engagement scores.
0:26:07 – Wow.
0:26:08 – And more likely them to stay.
0:26:09 – I was talking to multiple venture capitalists
0:26:11 when I made the move for being an operator
0:26:12 to a venture firm.
0:26:14 The first talk to me, the recruiting cycle
0:26:17 was over six months before an offer came.
0:26:19 And the offer only came after I started talking
0:26:21 to Andreessen Horowitz and got to an offer
0:26:23 within a few weeks.
0:26:26 And then the six month person said oh, we’ll move fast.
0:26:28 And so I was so disillusioned at that point,
0:26:29 it was a pretty easy decision.
0:26:30 – Yeah, it’s very telling.
0:26:33 What have we learned from these other platforms
0:26:35 that we can incorporate into the platform
0:26:37 that’s better addressing a specific vertical?
0:26:40 What is some of the kind of knowledge that does apply?
0:26:42 – So we use these competitive tactics, right?
0:26:44 When a hospital recruiter logs in,
0:26:46 they know they’re competing with other employers
0:26:47 at the same time.
0:26:48 There’s a time limit.
0:26:48 – You gamify it?
0:26:50 – Yeah, yeah. – That’s awesome.
0:26:51 – There’s a time limit.
0:26:52 There’s a seven day countdown
0:26:54 for them to send their interview requests.
0:26:56 And they can see which candidates are popular.
0:26:59 So we’re creating urgency, scarcity, and competition.
0:27:01 – That’s at e-commerce to only one left.
0:27:02 Yeah, that kind of thing.
0:27:03 – It works.
0:27:05 – So how is the adoption of this kind of thing?
0:27:06 Like do you hit resistance along the way
0:27:07 in certain areas?
0:27:09 Is there friction to getting these new platforms
0:27:11 integrated into the system?
0:27:13 – Okay, so this goes back to what Julie had said earlier
0:27:16 about ROI and the value proposition.
0:27:19 You have to have a really, really strong value proposition
0:27:20 and ROI.
0:27:21 And whatever you’ve come up with
0:27:23 has to be at least 10 times better
0:27:24 than what’s already out there.
0:27:25 So whatever we come up with,
0:27:27 incredible health needs to be at least 10 times better
0:27:29 than LinkedIn or Indeed or any of these other tools
0:27:30 that they’re using.
0:27:33 We now have over 150 hospitals in California
0:27:35 using our platform in less than 18 months.
0:27:37 Very short sales cycles.
0:27:39 Because this is a hair on fire problem.
0:27:43 The CEO and everyone in the C-suite cares about staffing
0:27:46 and getting great talent and getting amazing nurses
0:27:49 in permanent roles quickly impacts their bottom line
0:27:51 and both revenue and cost.
0:27:52 – That’s the other sort of case
0:27:54 for why you need vertical solutions
0:27:57 is the supply side of the market also has to believe
0:28:00 that they are gonna be better represented on this platform
0:28:02 than your sort of generic horizontal platform
0:28:03 and that there’s something new to offer there.
0:28:06 So what are you seeing on the response from the nurses side?
0:28:08 – Yeah, it’s similar in that the value
0:28:09 has to be really clear to them as well.
0:28:11 Right now we’re the only platform out there
0:28:14 that says create a profile, sit back and relax,
0:28:16 employers are gonna apply to you.
0:28:18 So employers send them interview requests
0:28:19 and then the nurse gets to decide
0:28:21 which ones to accept and which ones to decline.
0:28:25 And what that does is it gives more control to the nurse
0:28:27 and this is something that they do not normally experience.
0:28:29 – Yeah, it sounds like a profession rife
0:28:31 with a feeling of lack of control actually
0:28:33 that you’re constantly being told what to do
0:28:34 and where to go.
0:28:37 – Yeah, this is a highly mistreated
0:28:39 and underserved group of workers.
0:28:41 The vision is to help them live better lives.
0:28:42 It’s about the healthcare professionals.
0:28:45 Whoever creates a product or an experience
0:28:47 and treats this group of workers the best,
0:28:49 appreciates them, celebrates them,
0:28:50 gives them an amazing experience.
0:28:51 All of that is gonna win.
0:28:52 – That’s interesting.
0:28:55 I blogged years ago about in two-sided marketplaces,
0:28:57 the consumer side is the one that you should have
0:29:00 to optimize for even if the institutional side
0:29:01 is the one that pays you.
0:29:03 You know, at eBay you optimize for the buyer,
0:29:05 at OpenTable you optimize for the diner here,
0:29:06 you optimize for the nurses.
0:29:09 – The folks in the recruiting office of the hospital
0:29:11 are actually consumers, right?
0:29:12 And they’re gonna go home
0:29:15 and they’re gonna use their iPhone and shop on Amazon
0:29:17 and have these magical experiences
0:29:18 in other parts of their lives.
0:29:19 And then they get to work
0:29:22 and they have these sort of highly legacy
0:29:25 ossified archaic systems that sort of overall trend
0:29:27 is what’s driving a ton of uptake
0:29:29 of these novel technology solutions.
0:29:32 – A few of the hospitals use Oracle PeopleSoft,
0:29:34 some use Teleo, some use, you know,
0:29:36 there’s lots of different software,
0:29:37 whether they’re applicant tracking systems
0:29:39 or more general HR systems.
0:29:41 And we’re there and they’re like,
0:29:44 oh, I have to use a 20 page manual to create a job rec.
0:29:45 – Oh my gosh.
0:29:46 – Right?
0:29:47 And you look at it and it’s like, oh my God,
0:29:50 this software looks like it’s from like the 80s.
0:29:54 Like when software was first like a thing, right?
0:29:56 And so when we come in,
0:29:58 we’ve even had chief nursing officers say like,
0:30:00 oh, wow, it looks like a dating app.
0:30:01 – Yeah, I was gonna say that earlier
0:30:02 when you were checking the nurses.
0:30:05 – Yeah, match.com for nurses in hospitals, right?
0:30:06 And so–
0:30:08 – You don’t have to fake profiles and spam.
0:30:10 – Yeah, yeah, yeah, yeah, yeah.
0:30:11 Certainly a lot of the features we’ve built
0:30:14 into the platform we’ve borrowed from consumer apps,
0:30:17 like the countdown timers and who’s popular
0:30:20 and kind of creating urgency and scarcity in the platform
0:30:23 and just simply making it beautiful and easy to use.
0:30:24 – You see now for the first time,
0:30:28 it really grounds up demand from clinicians
0:30:29 asking for better tools.
0:30:33 They no longer are able to deal with kind of these legacy EHRs
0:30:35 that have been implemented across the industry.
0:30:36 One of the challenges has been,
0:30:40 it is just so damn hard to sell to these organizations, right?
0:30:42 If I’m looking at two options as an entrepreneur,
0:30:45 either I build software that I need to somehow figure out
0:30:48 how to distribute to this industry,
0:30:50 make them change the way that they operate,
0:30:53 deal with thousands of employees at these organizations
0:30:54 that all have their own agendas,
0:30:57 versus building sort of outside of the system,
0:30:59 let’s say a full stack primary care clinic
0:31:02 that I can build my own technology from the ground up,
0:31:03 eat my own dog food.
0:31:05 And therefore the packaging of that offering
0:31:07 may look like a direct to consumer offering,
0:31:08 but at the end of the day,
0:31:10 I’m trying to solve the same problem,
0:31:11 just sort of from the outside.
0:31:13 And so those are the two attack vectors
0:31:14 that we see out there.
0:31:15 I totally agree that in some ways,
0:31:18 the clinicians are sort of the forgotten end users
0:31:19 of this whole thing.
0:31:21 And you see a lot of emphasis on the patient,
0:31:23 but at the end of the day,
0:31:25 the high leverage point is actually putting better tools
0:31:26 in the hands of clinicians.
0:31:29 – Yeah, I mean, I meet many founders
0:31:30 who are working in the healthcare industry
0:31:32 and they’re usually building applications
0:31:34 that are patient facing, which is great.
0:31:38 But I don’t see enough working on the backend of healthcare.
0:31:40 We took one part of it, which is staffing.
0:31:43 There’s certainly a ton throughout operations.
0:31:45 And there’s a lot of innovation needed
0:31:48 in basically the full stack of healthcare.
0:31:50 – So what kind of takeaways or advice would you have
0:31:52 for other founders building companies
0:31:55 in the particularly challenging space that is healthcare?
0:31:57 – Like many things in entrepreneurship timing
0:31:58 is everything, right?
0:31:59 The healthcare industry is at a point
0:32:02 where the cost pressure has never been more intense
0:32:04 because reimbursements are going down
0:32:07 and the competition is fierce among providers.
0:32:10 And that creates opportunities for entrepreneurs
0:32:12 and a bunch of hospital executives
0:32:13 that may be willing to listen.
0:32:15 And so when you’re creating your product,
0:32:16 you need to come up with something
0:32:17 that’s at least 10 times better
0:32:19 than what’s already out there.
0:32:20 Like at least 10, and you can measure that however you want.
0:32:22 10 times better, 10 times cheaper,
0:32:24 10 times more efficient, 10 times faster,
0:32:25 like whatever it is.
0:32:29 And have a really, really strong value proposition
0:32:33 that clearly ties to ROI and impacts the bottom line
0:32:35 for the hospital, clearly impacts it.
0:32:38 Not like indirectly, but directly impacts it.
0:32:39 – That’s awesome.
0:32:41 Thank you so much for joining us on the A16Z podcast.
0:32:41 – Thank you. – Thank you.
0:32:50 [BLANK_AUDIO]
“Constant attention by a good nurse may be just as important as a major operation by a surgeon”, diplomat Dag Hammarskjöld once observed — and that may be more true today than ever before. For most of us, nurses are essentially the face of the healthcare system: the person you’ll see the most of while you’re in it, who will monitor your vitals, administer medications, hold your hand when you’re in pain or scared, answer all the questions you forgot to ask the doctor.
So in this episode, we take a look at the role of that unsung hero of healthcare — the nurse — at an industry level. Iman Abuzeid, CEO and co-founder of Incredible Health (a hiring platform for nurses), and a16z general partners Julie Yoo and Jeff Jordan discuss with Hanne Tidnam how the scope of the job is changing today and why; what’s driving the looming nursing shortage crisis, and ways we can help solve it; what it’s like to build a new marketplace platform in healthcare; and how best to introduce innovation into the healthcare system overall.
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363: 10 Creative Side Hustles That Make Real Money – Part 2
This week’s show is a re-take on last year’s Thanksgiving episode on 10 Creative Side Hustles that Make Real Money.
That show was a hit, so I’m returning to that format for another round.
Some of these will you have kicking yourself not thinking of it yourself, and some of these are 6-figure businesses you could literally start tomorrow.
Here are the 10 creative side hustles I cover in this episode:
- The 7-Figure Lemonade Stand
- The World’s Most Boring Podcast
- Local Dog Poop Pick-Up
- The 6-Figure Dog Walking Business
- The 7-Figure Email Newsletter Business
- The Ambient Noise Alexa Skill
- Big Bat Houses
- The Niche Service Provider Directory
- The Niche Productized Service
- In-Person Classes
Enjoy!
Full Show Notes: 10 Creative Side Hustles That Make Real Money – Part 2
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How to Change Your Mind (Rebroadcast)
There are a lot of barriers to changing your mind: ego, overconfidence, inertia — and cost. Politicians who flip-flop get mocked; family and friends who cross tribal borders are shunned. But shouldn’t we be encouraging people to change their minds? And how can we get better at it ourselves?
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E43: Nir Eyal – How to Become Indistractable
On this week’s episode of The Diary of a CEO, I sit down with Nir Eyal, an Israeli-born American author, lecturer and investor. Nir released his first book in 2014 “Hooked: How to Build Habit-Forming Products” and it became a Wall Street Journal Interna…
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#398: Peter Attia, M.D. — Fasting, Metformin, Athletic Performance, and More
Peter Attia, M.D. — Fasting, Metformin, Athletic Performance, and More | Brought to you by HumanN’s BeetElite and Peloton.
Dr. Peter Attia (peterattiamd.com, TW: @PeterAttiaMD, IG: @peterattiamd, FB: @peterattiamd) is a former ultra-endurance athlete (e.g., swimming races of 25 miles), a compulsive self-experimenter, and one of the most fascinating human beings I know. He is one of my go-to doctors for anything performance or longevity-related. He is also easily the best quarterback and sherpa for the US medical system I’ve ever met.
But here is his official bio to do him justice:
Peter is the founder of Attia Medical, PC, a medical practice with offices in San Diego and New York City, focusing on the applied science of longevity. The practice applies nutritional biochemistry, exercise physiology, sleep physiology, techniques to increase distress tolerance, lipidology, pharmacology, and four-system endocrinology to increase lifespan (delaying the onset of chronic disease), while simultaneously improving healthspan (quality of life).
Peter trained for five years at the Johns Hopkins Hospital in general surgery, where he was the recipient of several prestigious awards, including resident of the year, and the author of a comprehensive review of general surgery. He also spent two years at NIH as a surgical oncology fellow at the National Cancer Institute where his research focused on immune-based therapies for melanoma. He has since been mentored by some of the most experienced and innovative lipidologists, endocrinologists, gynecologists, sleep physiologists, and longevity scientists in the United States and Canada.
Peter earned his M.D. from Stanford University and holds a B.Sc. in mechanical engineering and applied mathematics.
Peter also hosts The Drive, a weekly, ultra-deep-dive podcast focusing on maximizing health, longevity, critical thinking and a few other things. Topics include fasting, ketosis, Alzheimer’s disease, cancer, mental health, and much more. Subscribe on Apple Podcasts, Spotify, Overcast, or wherever you listen to podcasts.
Please enjoy!
This podcast is brought to you by HumanN’s BeetElite, the endurance superfood and nitric oxide activator. HumanN’s BeetElite can help extend endurance, improve energy and stamina, and increase oxygen delivery throughout the body. It provides the nitric oxide equivalent of six whole beets, and BeetElite is trusted by hundreds of elite teams, athletes, and organizations all over the world, so you know you’re getting a top-notch performance product.
BeetElite is Informed-Sport Certified, and the team at HumanN is making an offer exclusive to my listeners: Take your performance to the next level with BeetElite by going to LiveHuman.com/Tim to get 20% off your first purchase!
This podcast is also brought to you by Peloton, which has become a staple of my daily routine. I picked up this bike after seeing the success of my friend Kevin Rose, and I’ve been enjoying it more than I ever imagined. Peloton is an indoor cycling bike that brings live studio classes right to your home. No worrying about fitting classes into your busy schedule or making it to a studio with a crazy commute.
New classes are added every day, and this includes options led by elite NYC instructors in your own living room. You can even live stream studio classes taught by the world’s best instructors, or find your favorite class on demand.
Peloton is offering listeners to this show a special offer: Enter the code you heard during the Peloton ad of this episode at checkout to receive $100 off accessories with your Peloton bike purchase. This is a great way to get in your workouts, or an incredible gift. That’s onepeloton.com and enter the code you heard during the Peloton ad of this episode to receive $100 off accessories with your Peloton bike purchase.
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