Medsider: Learn from Medtech and Healthtech Founders and CEOs - The Hidden Drivers of Clinical Trial Success: Interview with Rivermark CEO Dr. Adam Kadlec

Episode Date: December 16, 2025

In this episode of Medsider Radio, we sat down Dr. Adam Kadlec, practicing urologist and co-founder of Rivermark Medical.Rivermark is a clinical-stage company developing FloStent, a first-line, reversible device therapy for benign prostatic hyperplasia (BPH).Before launching Rivermark, Adam built a thriving urological practice in Milwaukee and consulted for several device companies — experiences that ultimately revealed how early true device development begins and why physicians rarely get the chance to influence innovation upstream. Partnering with medtech operator Andy Doraiswamy, Adam transitioned from clinician to CEO and is now leading Rivermark through its pivotal trial.In this interview, Adam shares why workflow integration is one of the most overlooked drivers of adoption, how physician-innovators can build the right decision-making infrastructure, and why understanding who actually enrolls patients at clinical sites can make or break a trial. He also touches on the mindset required to stay resilient through the ups and downs of building a medtech startup.Before we dive into the discussion, I wanted to mention a few things:First, if you’re into learning from medical device and health technology founders and CEOs, and want to know when new interviews are live, head over to Medsider.com and sign up for our free newsletter.Second, if you want to peek behind the curtain of the world's most successful startups, you should consider a Medsider premium membership. You’ll learn the strategies and tactics that founders and CEOs use to build and grow companies like Silk Road Medical, AliveCor, Shockwave Medical, and hundreds more!We recently introduced some fantastic additions exclusively for Medsider premium members, including playbooks, which are curated collections of our top Medsider interviews on key topics like capital fundraising and risk mitigation, and 3 packages that will help you make use of our database of 750+ life science investors more efficiently for your fundraise and help you discover your next medical device or health technology investor!In addition to the entire back catalog of Medsider interviews over the past decade, premium members also get a copy of every volume of Medsider Mentors at no additional cost, including the latest Medsider Mentors Volume VII. If you’re interested, go to medsider.com/subscribe to learn more.Lastly, if you'd rather read than listen, here's a link to the full interview with Adam Kadlec.

A thing I really wished I would have asked earlier on a lot of the sites is who recruits patients for you? Who is your recruiter and what's their process and how successful it is in? I think that might be the most important thing. Identify who's finding the patients and it's usually not the docs, not just not the study coordinator. I mean, you don't know who it is, but I think it's different everywhere. That, to me, is something I would want to know at every site.

Welcome to MedSider, where you can learn from the brightest founders and CEOs in medical devices and health technology. Join tens of thousands of ambitious doers as we unpack the insights, tactics, and secrets behind the most successful life science startups in the world. Now, here's your host, Scott Nelson. Hey, everyone, it's Scott. In this episode of MedSider, I sat down with Dr. Adam Cadleck, co-founder and CEO. of Rivermark Medical, a urology-focused med tech company developing flow stint, a first-line device treatment for benign prosthetic hyperplasia or BPH as most of us know it. Under his leadership, Rivermark has raised more than $36 million and is conducting a pivotal clinical trial.

Prior to founding Rivermark, Adam was a high-volume urologist in Milwaukee and consultant to multiple medical device companies. Here, a few of the key things that we discussed in this conversation. First, design for the workflow physicians already have, not the one you wish they had. Adoption barriers aren't just clinical, they're operational. Flosin works with equipment urologists use every day, turning diagnostic visits into therapeutic interventions without new capital, training, or scheduling complexity. Technologies that slide naturally into existing practice patterns

face less friction and scale faster. Second, in clinical trials, identify who actually recruits the patients, and it's usually not the PI. Site performance often hinges on a single individual who talks to patients, follows up, and drives enrollment. Ask up front, who is your recruiter? What's the process? What's the track record?

This question predicts trial momentum better than investigator reputation. Third, raise capital in stages. Communicate constantly and protect your mindset through the grind. Rivermark launched with $2.5 million and proved value at each milestone before raising more. The hardest part isn't mechanics. It's the emotional toll. Adam notes the importance of fighting a way to stay positive because investors respond to conviction and sustaining that energy matters as much as the pitch itself.

All right, before we dive into this episode, I'm pumped to share that volume 7 of Medsider Mentors is now live. This latest edition highlights key takeaways from recent Medsider interviews with incredible entrepreneurs like Bill Hunter, CEO of Canary Medical, Brian Lord, CEO of Pristine Surgical, Don Crawford, co-founder of Safion and current CEO of Corvista Health, and other proven MedTech founders and CEOs. Look, we get it. Keeping up with every MedSider interview isn't easy. That's why we created Medsider mentors. These ebook volumes distill the best practices and insider secrets from top founders and CEOs, all in a downloadable, easy-to-digest format. To check the latest volume out, head over to medsiderradio.com forward slash mentors.

Premium members get free access to all past and future volumes, plus a treasure trove of other resources. If you're not a premium member yet, you should definitely consider signing up. We recently revamped Medsider with swanky new features, especially for our premium members. In addition to every volume of Medsider mentors, you'll get full access to our entire interview library dating back to 2010. You'll also get Medsider playbooks, curated guides packed with actionable insights and topics like fundraising, regulatory challenges, reimbursement strategies, and more. And if you're fundraising, don't miss our exclusive investor database, featuring over 750 life science VCs, family offices, and angels. We've even created three

custom packages to help you with your next fundraise. Learn more about Medsider Mentors and our premium memberships by visiting MedsiderRadio.com forward slash mentors. All right, without further ado, let's dive in the interview. All right, Dr. Adam Cadillic. Welcome to Medside Radio. I know this is a very informal conversation, but I did want to mention you're a doctor. So, but welcome to the show. Thank you, Scott. Great to be here. Appreciate you having me on. We're excited about this. Yeah, looking forward to the, looking for to learning a little bit more about kind of the, yeah, not only your background, but really your journey, you know, building, building rivermark. So with that said, you are practicing

physician and both a med tech, you know, entrepreneur simultaneously. So give us a, you know, I provided a brief bio on your, on your background at the outset of this episode, but like, let's start there. Give us like a one or two minute overview kind of leading up to founding the company. Sure, yeah. So, I mean, as you said, practicing physician by background, very typical training pathway, went to college, went right into medical school, did a urology residency, did a fellowship, went into practice. So the same thing really all practicing physicians do. And it had really no background to innovation during my training. I think unfortunately I probably would have discovered it earlier, but really just a typical training pathway. And it wasn't until my first actually a couple

years of practice when I started using medical devices very significantly in my practice that I became interested in them, how they were made, how they worked, how some were different than others, how some were potentially better than others. And I really actually enjoyed just, chewing the fat with the reps and I got to know some reps and that led to some device consulting opportunities of hey here's a guy's a high volume urologist likes to talk shop and i think my aha moment was on some of those experiences you'd start talking to some of the people that had been working with the product for a while it's like geez this thing's been around for like a decade as far as when it got started and what i'm thinking is new is a practicing doc or just coming to market

has been around for an awfully long time. And I've always been like a learning curve person. And I think I realized that for device development, that that early phase was much, much earlier than I thought. And so once I had that moment, then I really said, okay, this is something I'm interested in. And then I started really to do a purposeful exploration of the device development space. I'd just say healthcare innovation in general.

Next really critical moment for me was actually meeting the co-founder of Rivermark Andy Dora Swami, who's not a physician, had been in the med tech world, and we started to compare notes, and we just really hit it off, developed a great relationship, and that was the spark that led to Rivermark, actually. And I often tell practicing docs, now I get a lot of people hitting me up saying, you're kind of living the dream here as a doctor who's getting to develop an idea. Very few people get to do that, and I know I'm very fortunate, but what I always tell people is you kind of early on need to seek out another person who's not a doctor because you don't see a lot of two doctor teams doing stuff.

It's often you'll have a physician and a non-physician. So for me, that was Andy. And once we decided to move forward with the project, it took about a year to get everything together, get the company formed, get the money raised. And we were off of the races in 2021. So we've been at it for about four years now. Okay.

Yeah, four years. We're recording this in, uh, Yeah, about almost exactly, you know, four years, four years later, to the Rivermark, if you will. Punning, pun intended. But that's a really good point. Like, oftentimes the best early teams, or teams that are really efficient in those early days of a device startup, is that, that duo that you mentioned, right? It's physician plus maybe engineer or maybe like someone with a little bit more, I guess, business chops in those early stages, right? And that tag team works extremely, extremely well.

especially in those in those early days and maybe we'll have a chance to kind of dig into that in a little bit in a little bit more detail but now that uh that folks have a little bit better understanding of your your background kind of prior prior to to co-founding river mark give us a sense for kind of the flow stint system and i think this probably should be fairly easy for you since you're used to explaining explaining it to patients but but almost treat me like a patient right like what is what is the you know what are we solving for like what's the underlying you know clinical need and like why is why is flow stent different yeah it's a good question because it it was really in talking to patients and seeing a lot of patients and counseling them on options that

that I think we identified the unmet need. But I would say first and foremost to a patient or anybody else, it's a very simple device that's used to treat BPH, benign prosthetic hyperplasia, enlarge prostate. When I talk to patients about it, I'd say this, you know, you getting this condition if you're a male is as inevitable as getting gray hair or getting wrinkles. So age-related disease, not prostate cancer. We make that clear very early on, but you know, you've got a ton of options here. So you're bothered by the way you urinate. It's because of an enlarged prostate. And, you know, here's sort of the menu of options. And what the flow stent is intended to be is a first-line device option. So like many chronic medical conditions of which BPH is one,

first-line therapy, what almost everybody does first and what almost everyone is just doing is taking a daily medication. I would tell patients this is like a forever medication. It's like a high blood pressure pill. Your prostate's never going to get smaller. Your symptoms aren't going to get better. So this is going to reduce the symptoms you're experiencing, but it's not going to cure you of the condition. Now, there are device therapies that really do set the clock back. And there's receptive therapy where you're going to the operating room, general anesthesia, different risk profile. So you're kind of going through all that with the patients and what the flosin is designed to be is something that you can position almost next to medications in the treatment algorithm. And we don't

really have anything like that. And that's because the procedural or device therapies for BPH that we have available today fundamentally or irreversible. Once done, they cannot be undone. It can always stop a medication. You can't undo a procedure. And I would often tell that to patients, I can't undo the surgery. So once we do that, we're both stuck with the outcome of it. And it's often good, but if it's not good, I can't go back and not do it. But with this, you really could go in and undo it. So it's a reversible technology.

It's a stent. It's a night and all stent, which I think most people and certainly most patients are familiar with from the cardiac world that holds the urinary channel open. It provides support to the inside of the urinary channel so that the tissue for BPA that's growing and obstructing the channel, the root cause of the urinary issues people face, it alleviates that pressure. But because it's a stent, it doesn't change the tissue in any way.

It's not intended to remodel the tissue. There's no ablation. There's no bleeding. And so retrieval is always an option for the patients. And so having this reversible device, therapy. That's, I think, probably the core unmeted need. The other thing we probably don't talk about enough is a lot of things we do for BPH to patients hurt and we're migrating toward, I say we're kind of there now doing a lot of procedures in the office. And so patients

are awake or they're lightly sedated. And just having the procedure done is it's painful. And it's scary. And there's a recovery period because the tissue has to heal. Many people go home with a catheter, which the doctors are like, oh, it's a catheter for a couple days. But you talk to a patient, and that's really significant for them, just the idea of getting in their car with a catheter. How do I do that? How do I take a shower? What do I want to go out to dinner?

What if, like, something happens in my house and I got to go fix it? I mean, they worry about it. And so to have this catheter-free, stent-based technology, I just think it's going to be very attractive to a lot of people. It's not going to be for everybody, but there's a lot of BP patients out there. And I think there's a, there's a, there's a, there's a, there's a lot of them that we're really not capturing now who will go for something like this. Got it. Yeah, that's super, super helpful background. I can tell you've done that a couple

times, maybe. At least, at least the, uh, the kind of about it before. Talk about it. The patient-centric version, for sure. But I'm looking at the website now, which is rivermarkmedical.com. So just as it sounds, rivermarkmedical.com, all one word. We'll link to it in the full write-up on Medsider, but for those that are listening and don't get to that full write-up, highly encourage you to check out the website. again, Rivermarkmedical.com, but I'm not going to play the animation right now. But let's fast forward into maybe, I'm not exactly sure your timelines, but a year, two years down the road,

this is now proof, you know, hypothetically approved by FDA. It's being used in, you know, by endo urologists, you know, around the country. I presume this is like, walk, just touch on maybe the patient experience. This is like a, there's no january anesthesia. Is it like a, what, 15, 30 minute? Like, it's probably a pretty quick procedure, I would imagine, right? And kind of in and out, so to speak? Relatively quick. Yeah. So one thing I didn't mention talking about the product, which I'll mention now because it's important, is how it integrates into the workflow of how we evaluate and treat BPH now. So one of the critical differentiators of the flow stent versus other prosthetic stents, and there are others, is that the stent can be delivered with existing equipment that's already in the physician's office. So there's a device called a flexible cystoscope that urologists use all day every day.

We use it to look inside the bladder of the people that we see. So I always say it's kind of like our stethoscope. You almost have it hanging around the wall. You can't wear it around your neck, unfortunately. But it's basically arms reach away. And the flow stent is compatible with any type of that type of scope. And so what your oldest are doing now is they're seeing patients with BPH, it's making a clinical diagnosis. So you hear the symptoms.

sounds like this guy is BPH, and then we're often doing a cystoscopy on the patients to evaluate their anatomy because they have so many device options. You want to give them a personalized recommendation. That's a diagnostic procedure. What the flow stent can be is a therapeutic option and implantable that's also retrievable that can be delivered essentially during the diagnostic cystoscopy. And that's something that we really don't have right now, and that makes the flow stent very special, and it makes the integration into most physician's practices, I think, very easy. So if you're a patient, you're getting the same experience that you're getting anyway. You're coming in, you're seeing the doctor, you're having a cystoscopy,

you're being counseled on your options, but now you have an option that potentially you can get it right then and there. You can see how you do. The doctor can see how you do. And if things are going well, you can keep it. If you decide that it's not for you or if you just want to pursue another one of the many options for BPH, you've burned no bridges. And so for patients, I think we talk about option preservation. And when I would see people in the clinic, that's really where people get stuck is where, well, you just explain four options to me. I'm not sure what to do because I got to pick one of them. And if I pick A, I can't do B. But what if you could pick A and still do B? Yeah. That's really the value proposition to the patients and also for the physicians. And the other thing that I'll mention is what we know scientifically, we really know this scientifically, is that patients with BPH do better with device therapy and with receptive therapy than on medications. They have a greater symptom reduction. Their quality of life is higher. The adverse effects are actually are less. And the stickiness is better. So people, it kind of lasts longer. And so.

doing the patient's a service by getting them into the device arena essentially. And I think a lot of physicians are going to appreciate that. That movement is already starting in our field to try and get these guys off these chronic meds. Yeah. Yeah. Those are good thoughts. And it's interesting. Most of my hearing you explain kind of the optionality, right, and the need to preserve options, right, for future intervention. It's very similar to like what I see in the world of of cardiology, right? and this move, it's kind of this, this move away from, in an ideal scenario, not leaving an implant behind, not leaving a stint behind, right? And unfortunately, it's hard to, it's hard to have something like the flow stents and the coronary artery that you can maybe remove at some point. That's a little

bit difficult, but, but you kind of understand kind of where I'm going with that thought. So it's interesting how that framework sort of applies and other specialties. So with that said, I want to get to kind of the meets of the discussion to learn a little bit more about, you know, your direct experience is building a rivermark. But with that said, we talked about, You founded the company four years ago. Give us a sense for kind of where you're at as of, you know, we're recording this in September of 25 here. Where's the company at in terms of its life cycle? Well, we're knee deep in our pivotal study right now. So we're just in the thick of enrollment. It's going from my perspective fantastically well. A lot of excitement from

the physicians that are using the product. Our team is doing great. So we are working on getting that pivotal study done so that we can get a device FDA approved and we can move forward. ultimately with bringing the product to market. Got it. I'm assuming a class three device then or class two or? Our current understanding is it's a class three. Okay, class three. Okay.

For an understanding. Got it, got it. Okay. But it's been in the throes of a pivotal trial. So yeah, definitely exciting times for a remark. I mean, it's just any more, it seems like such a, not seems, it is. It is such a monumental kind of feat just to get to an IDE trial, right? It is.

You know, and you're in the thick of it. So that's really, I mean, kudos to you and your team for kind of getting this far. and then, you know, the obvious next step is, right, to see this potential, like, really cool technology, you know, be available for, for physicians and their patients. So that's really cool. So again, everyone listening, Rivermarkmedical.com, highly encourage you to check that out, Rivermarkmedical.com. We'll link to it in the full write-up on MedSider.

So, but Adam, let's spend the next, like, 20, 30 minutes kind of going through some functional questions, really kind of diving in to, you know, your direct experience is, right, building Rivermark, right? And the first one, I guess, is, like, more of an obvious one. And so it's really related to kind of your unique perspective, right, as a practicing physician, building a device company in the exact arena, right, that you work with. And so for maybe the critics that would say, oh, a physician can't actually build a startup, right, they have to kind of leave their practice behind.

I'd like to take, like, get your perspective on that because it's undoubtedly, you bring a very unique, you know, unique kind of lens, even from the earliest kind of stages of development. Give us a sense of what that's been like at Flosin from the earliest days. I would agree that at a certain point to lead a startup, a physician does need to leave their practice. That doesn't mean they have to never touch a patient again, but as far as having a practice is a lot of responsibility. And for me, I mean, as a high volume, urologist, I have patients with cancer, I have patients

coming in with issues after procedures, you've got to leave that behind eventually. but most people realistically aren't going to do that unless they really are the one who's going to be the CEO. So I definitely agree and I actually give this talk to physicians that is just like, hey, there's a lot of ways to get involved. So you don't need to invent something, raise money, do trial. I mean, you don't need to do what I'm doing. And I would say for most people, it's the wrong thing to do. But if you want to do it, yeah, I mean, it is a full-time job. There's no question about that. I think that for your, well, I can really speak for me is that I just had to phase myself really

out of clinical practice. So it wasn't like I woke up one day and said, I'm leaving practice and I'm going to invent this thing. I mean, there were multiple steps where I was, but I, you know, one thing I did very early on that I would encourage anyone who's interested in innovation to do is I started to reduce my clinical hours. So I really never worked more than four clinical. days per week. And I was fortunate to be in groups where that was supported. I could be busy enough

in four days. I was still taking full-time call. I was still productive. I was still a fully fledged member of the group. But I had a day to myself. And I would use that day and that time and that bandwidth to just try and learn. So there was a couple of years of just really just learning. And I don't think there's one single way to do that, but I do think you have to make time. the average your oldest works 55 hours a week average so that doesn't leave a lot of time to do other things unless you're like supermanic which i'm not i like to get eight hours of sleep so i had to find the time by reducing clinical so that that's a very important step one and it and it was for me and then at some point you do have to have that conversation with yourself with your mentors

with your partner and just say they almost you don't have to have to have that conversation with yourself with your mentors and just say they want to do this. Yeah. Yeah. That's a really good, that's a really good point. And there's a lot of, as you can imagine, there's a lot of physicians that listen to this program that are a little bit more, they have an entrepreneurial bias, right? They enjoy startups, but they don't necessarily know how to maybe take that first swing, right? And how to how to view it not just in the acute kind of time frame, but like looking three, four or five years out if this thing has legs, what does that look like for me as a practicing physician? So I think that's probably a healthy, healthy framework that go into that eyes wide open that at some point, if you want to, if you want to really run run a company it's going to require full-time focus and that it doesn't have to mean you you jump off the cliff but it does mean that you're going to have to make these decisions to kind of be in the phase you don't necessarily wait for the perfect opportunity either so your first swing isn't going to be big swing I had a couple ideas that went nowhere before flow stent so it's probably the right idea that's important but you got to know the process and you got to know the people and you can come up with an idea in the shower you can

immediate, I mean, the invention can, it's a bolt of lightning. But all the stuff that actually is required to actualize it takes, takes time. Yeah. That's a, yeah, I'm glad you mentioned that, right? Ideas are a diamond. We've, we've all heard that, but I think, I think your point around, um, around just like, like, and it's, it's sort of one of the same, right? You've got to know the right, you've got to have like the, the right understanding, the right people, right, to begin to like, you know, take, take practical steps towards, like, seeing this idea become a reality. But oftentimes, your first attempt at that is not going to go well, right? You're going to trip a lot.

You're going to fall over. And so, yeah, if you're waiting to kind of take action on the perfect idea, that's highly unlikely that you'll hit, you'll hit a single, let alone a double or triple right on that first idea, right? It's really about kind of like continuing to take swing after swing and rep after rep until you start to, so that learning curve, right, begins to get to shorten. So with that stead, you've got, you do have a little bit of a business background, right, with your, you know, your MBA from Kellogg. So I'm getting the sense that you kind of, you leaned into kind of the business world, you know, fairly on maybe in your, in your clinical career. But for those other physicians that are like listening to this and are like, you know, maybe they're the physicians that have commented to Adam, you're living the dream, right? You're actually doing this, right? What are like beyond just like, you know, willing to take swings? What else comes to mind, right? Like what other, in that talk that you said, you give? Like, what are there a couple of key kind of tips that for other physicians that do

legitimately want to have, you know, they've got, they've got a couple ideas that they're legit and want to do, want to do take action on those? Yeah, I mean, a couple things I think I've learned and observed. Number one, I would say you've got to learn the process. So again, I mean, ideas dime a dozen, idea really has almost no value at all. What has value is an idea that that's living in like a little ecosystem that can actually build it. And so I think if you're interested in innovation, interested in development, whatever, I mean, you've got to learn the process.

And that, again, that's something. There is no recipe for that. You've got to figure out your own way to do that. And then another thing I tell physicians in particular is think less about getting a degree or being qualified to do something and think more about building a profile. Because you can really control that. Now, we're like degree junkies. And that's because, I mean, I'm in high school.

And I got, I got to get all the age, got a valetorian so I can go a really good college. And then I got to take all the hard class, do honors, take the MQI, and I got to get my bachelor's. And then I go to med school. And then I do all that stuff. And I got to be AOA. And I got to do the boards. And then I'm going to get a really good residency.

And you kind of get these badges along the way that allow you to, like, walk through the next gate. And as you know, in innovation and in business, that it's really not like that as much. We're in a very hierarchical, structured profession. It's like the military. You've got to have the badge. And so I see a lot of physicians interested in just anything non-clinical. And they feel like, well, let me get that badge first so I can do it. I can't be the CEO of a hospital because I don't have a master's degree.

And, you know, there are some jobs that probably do require it. But, I mean, it's, I would think more about profile building. And the degree may be part of the profile you're trying to build. And for me, that was the case. So doing the NBA, that was a big decision. I don't think it helped me start Rivermark. I think it's helped me be a better leader. And I want, I mean, I want, I think of myself as a leader. I want to be an excellent leader. That is a very high ambition of mine is to be, is to just be a great leader. And so that degree undoubtedly helped me build out that part of who I wanted to be. be as a professional. But, you know, it's not something where you get your master's or your MBA and then like a business job appears on the other end. And that was some advice I got. And then another piece of advice I got that was important, at least for me. And this actually came from a guy who was practicing physician for many years and then worked as a pharma executive in a CMO type of role.

And he said, one thing you have to consider very early on. This was just thinking valuable advice is do you want to make medical decisions or business decisions? And I wanted to make business decisions. That was, I wanted to be in the room when the decision was made and to be part of that and to build a team up toward that as opposed to let me have your medical opinion against no offense to anyone who's in that CMO type of role. But they're typically asked for input. But when it really comes down to like, doing this or not doing this, they're often not

directly part of that decision. And so for me getting an MBA, I think, again, not that I couldn't do it with it. I mean, there's people to do it without an MBA, but it helped me build a profile of someone who wanted to more be a leader in business and a CEO than a CMO. Those are two really good, really good takeaways. And your first point, right, especially resonates with me because maybe less so now, but rewind the clock 10, 15 years ago, that concept of like having to get a bad. badge first, having to get the certificate first, right, as sort of like the entry to get through the gate. And that's like I would offer up the same advice to anyone asking, asking, you know, how do you start a company now? It's like, definitely don't go get an NBA, right? Well, if you feel

like you want to, that that's fine, but that's definitely likely not going to be the inflection point that, like, helps you accelerate your, you're learning in the world of like building, you know, company building or startups. It's actually just taking swings, right? Emmercing yourself in that ecosystem, that network, you know, there's a lot of, like, figuring out. If you want to start a company, you need to start a company. And so you have to just build the profile of someone who's actually able to do that, and that typically doesn't. It's, you know, I'm sure it's the same.

You want to start a podcast? Start a podcast. Yeah, exactly, exactly. It reminds me how they go on. Yeah, you know, exactly. No, no, there's a lot of overlap there. You know, it's starting anything, right? Whether it's a company or just something in nature, oftentimes it's literally just doing the thing, right?

And that doesn't mean that you're just reckless with how you approach it. But ultimately, you do need just to start and start working and executing against that. And you're undoubtedly going to learn some things and pivot and iterate on that plan. But it reminds me of kind of going back in time here. I remember Tim Ferriss talking about how, like, at one point, he was thinking about doing his MBA. And instead, I think he took whatever amount of money that he was going to, it was like, I don't know, he was thinking about going to like Stanford or some prestigious school, maybe a Kellogg, right? And he was like, I'm going to allocate X amount of money.

Instead, I'm going to use that same money and experiment angel investing, right, in startups. I think this is back in like maybe 2009, 2010. This was like early when he first started podcasting. And he has a couple longer form pieces on his approach on how to. But it kind of reminds me of something similar, right? Like he wanted to, he kind of wanted sort of his MBA, right, to get better at maybe start up investing, but in reality he got way better at startup investing by just, doing it, right, by just investing and learning as he, as he, as he, as he, as he, as he kind of went

through that process. But now, that's really, really, really good points. Let's, let's transition to kind of your, your, your, your, you're thinking around Clint Reg in general, right? Which is obviously, especially the clinical side, right in your, right in your house. We talked about Rapid Three, which is the IDE trial that you're in right now. Like, let's go, go back in time when you begin to like really think about how to, how to get into an IDE trial eventually. Are there a few key things that. that you know now, right, but you maybe didn't fully understand, you know, three, two, three years ago when you were first kind of building out this kind of clinical journey for Rivermark.

Hey, everyone, let's take a quick break to talk about Fastwave Medical, the company I co-founded and lead as CEO. We're developing next generation intravascular lithotripsy systems, or IVL for short, to tackle complex calcific disease. The IVL market is valued at over $10 billion, but there's currently only one major player. In early 2023, we opened up an investment opportunity to our community, and within a month, we secured close to $10 million. Then in early 24, we closed an oversubscribed $19 million round in just a few weeks, bringing the total investment into FastWave to over $40 million.

Corporate interest in the IVL space is growing too, the $900 million acquisition of Bolt Medical by Boston Scientific, and then J&J's $13 billion acquisition of Shockwave Medical signals a lot of attention towards emerging IBM startups like FastWave. and we're making some serious progress. Fastwave recently received its seventh patent for our differentiated laser IVL platform for coronary applications. On the clinical side, last year we completed the first inhuman study of our advanced electric IVL system with some pretty compelling results. Next up in 2025, we have IDEE trials plan for both our peripheral and coronary IVL platforms. So if you're interested in investing in the fast-growing IVL market, sign up for our investor waitlist at fastwavemedical.com

forward slash invest. Again, that's fastwavemedical.com forward slash invest. Now let's get back to the conversation. Yeah, I can only speak to my own experience, which is end of one at this point, one company. So I haven't been fortunate enough to be able to do this a few times, like I'm sure a lot of people you host, but definitely have learned lessons. Moving quickly early was important for us. So, you know, not being perfect. And I actually just saw a post on this the other day, just applying some of that lean type of methodology. Like, you need to be comfortable with 60 to 70% certainty. Because if you, you know, the time and resources it takes to get from 70% to 100% start to become a problem. And so learning to trust your gut, that was hard. That's still hard for me.

I mean, we're sitting here in the middle of a study where I don't, know what the outcome is going to be. And no amount of work I could have done before this would have de-risked this to zero. And that is hard. That's hard for me because I'm a person that likes, I'm a hard worker. And I feel like a lot of this stuff I've rendered my life is like I put the time and I did this stuff. Now I get to do it, kind of what I was talking about before. And this is not like that. I mean, I could do everything right almost and we could still have a problem. And that's just a very personal lesson that we probably all have to learn during Klin Reg. I'm very much a believer in learning and succeeding through others. And so while I was

able to do a lot of stuff myself, because of my clinical background, I obviously had people who I was in thought partnership with. Early on, I wish I would have had more expertise in actual, like, operational elements of clinical trials. I didn't know what I didn't know. I also didn't have probably didn't have enough money to hire somebody who didn't know. So it was a bit by necessity, but we were so lean early on that I just had to do a lot of stuff myself. And if I did it again, I don't know if I would do it like that. Now, on the other hand, I've learned a bunch of stuff. So maybe I don't need that person next time, which could be good. So there is some value there. And I think there's no single way to do it. The other thing that's been helpful for me is just sourcing a lot of

opinions. And I've been surprised in this industry. I would say like med tech, clean reg. How often I hear somebody say, this is how you do A, B, or C. This is how it's done. And then you'll ask them, well, why? Oh, that's how we did at this other company. Okay. Is there like a, is there a reference on that? Is there anything we both can look at and just, and I bet this on people on my team, outside of my team. I've fallen prayer this before, but there's this sense of like, this is how we did it. And that's the right way to do it. And then I'll mean another person who will say, that's crazy. Like, you never do it that way. This is how you do it. And there is no source of truth. So like, again, in the clinical realm, I got a textbook. We've got our

boards. We have this canon of this is how things are done. And this world is, I'm surprised how I'm not like that it is, how it's a lot of people operating on anecdotal evidence and past experience and we had a win doing it this way and we got a loss doing it that way. So that way's wrong. It's like, well, maybe the loss wasn't from that. Yeah. And I just, so I've found that the best I can do as a CEO is to source many opinions and to listen to people and to try and dig a little deeper on why do you think what you think and try and make the best decisions I can. And I oftentimes will yield to people on my team or to consultants and say, I got to trust you on this, even though maybe I don't get it. And that's a hard thing to do, at least for me personally, to give up that

control. But I haven't found another way to do it because I can't know everything. I just can't. nobody can that that's another like key learning right too is like if you're we i had this discussion recently i think on the on the on the podcast if i remember correctly it might have been an offline conversation but about the same very same thing right of physicians coming in and and you're coming from a world where you are expected you don't for the most part to know everything right i mean this and then and it's it's a it's a it's a very um it's a significant kind of mindset shift right where you're now operating in a world where you simply don't you can't know everything right there's there's too many puzzle pieces that need to fit together um and to your point

a lot of those puzzle pieces like their edges aren't always straight, right? And they can be molded based on different opinions. And I really, like, I couldn't agree more with your thought process around and they're kind of almost, there's a lot of overlap between the two, right, of getting comfortable with making decisions with 60, 70, maybe maybe if you're lucky 80% of the information. And that doesn't mean that you don't make thoughtful decisions around that. But oftentimes the best way to make a decisive decision is getting a wide variety of opinions. But then at some point, you'd have to pull the trigger on that decision, right? And so, again, kind of, you know, getting to a point where you have 60, 70, 80 percent of the, you know, the information, that does mean that you,

you know, the best path there is to, is to talk to a lot of people, right? And most often, you're going to get different answers, which is good, which is good. But ultimately, you've got to pull the trigger and make a decision and move on. You do. Yeah, kind of reminds me. I can't share in totally in-depth information here, but we were having a meeting literally just yesterday and getting some questions from, from this outside R&D person who's engineer, who's very smart, clearly, but asking us some questions around how we got to a certain spot. And it's like, all very valid, great questions. But as a startup, we do, we do not have endless capital to focus on this one thing. Right. So we try to find the North Star metric. Yeah, yeah. We try to find

the North Star metric and make the best decision possible and move on. And I think it's going well. But yeah, that's like, that's the way things work, right? In the world of startups is like, you just, unfortunately, you can't get 95% there, 100% of the time, you know, 97% there. You just, you have to make the, you know, the best decision possible with, with less information. So one other thing, I guess, before we get to fundraising on the topic of kind of Clint Reg, I got to think that when it comes to enrollment, your, you know, your connections in this space probably have certainly, certainly like, helped with that process. It's not only mapping out kind of the trial design, but also enrollment oftentimes is like, especially with novel technology, right, like the flow stand. It's like that can become a very, very big challenge.

It becomes almost like a big marketing effort, right, to drive enrollment at these sites. How important has that been, you know, having connections, being in this space, having kind of that personal brand, right, that you mentioned earlier, has that been pretty instrumental in enrollment? Yeah, I mean, we think about enrollment all day every day. I was talking about it two hours ago. I'll be talking about it two hours from now with somebody else. So we're, that's, that's, that's the business of the company right now. That's our core business.

I wish I could say I've been helpful. Like, you mean, personally, I think, I think the technology is a relatively easy thing to convince patients that it's a, it is a safe, low-risk thing to do. So the simplicity, they can see it, they can touch it, the retrievability. I think first and foremost, patients, they don't want to get hurt and they don't want to feel like I made a mistake by signing up for this trial. Now, I'm sure some of our patients will say that. But we want most of them to say this wasn't a bad idea and it doesn't sound like a bad idea. So I had a hand in that, obviously. And it's interesting we're seeing with enrollment that the people were really targeting, which are these people that, you know, don't want to take a medication every day

and maybe are willing to try a device before they even try a medication. I'm actually getting a lot of those people. And that's a very encouraging sign for me that will have commercial success. As far as having a brand of knowing people, I mean, I don't have much of a brand. I'm like, I practicing urologist. I live in Milwaukee. I'm not in, didn't come out of like Y Combinator or whatever it is or Stanford Biodesign. I'm just kind of a guy that was, I think I had a lot of hunger. And I was purposeful and I was honestly blessed to just meet some very critical people at critical moments.

And so, but so it's great that I can speak to the investigators and, you know, the other stakeholders, I would say, having like a peer-to-peer conversation as a physician has been great. But as you probably know, I mean, the physicians oftentimes aren't the ones that really drive enrollment. We work with doctors where it's like, you just show me, you tell me where to show up to do the procedure. and then let's go out for let's go out for dinner and let me know when you're here again that's not everybody and but and you know yeah so i that's that's not everybody and but and you know yeah so i that it's like an important part of what rivermark is and what the product is does does translate back to me being a doctor but i didn't have a lot of assets to leverage in that maybe for the next one i will if this goes well i think that

will be helpful. But thus far, it's my first go-around. Yeah, got it, got it. Well, I'm glad you touched even on that last point about even, like, even as a physician, right, and having those peer-to-peer conversations, that doesn't necessarily mean all of a sudden that particular site's going to, like, be a high enrolling site, right? It's oftentimes their team and maybe even a couple, one or two individuals that are largely responsible for, you know, for getting, getting you know educating patients getting the comfortable with the procedure etc yeah so it's just good good point to remember a thing i really wished i would have asked earlier on a lot of the sites is who recruits patients for you who is your recruiter and what's their process and how successful

have they been i i think that might be the most important thing identify who's finding the patients you know and it's usually not the docs sometimes it's not the study coordinator i mean you don't know who it is but I think it's different everywhere that that to me is a something I would want to know at every site if I had to go through site selection again from even the very early days like first and human where we had a great experience because we had a physician that was aggressively recruiting and trying to do the right thing off for people and new stuff spend a lot of time with the patients that that person is so critical yeah that's such a a simple, straightforward question of when you're identifying sites, doing site qualls,

et cetera, like asking that question up front, who owns recruitment at this site, in essence, right? And making sure that you get to know that person, right? Because if you reverse engineer the problems that often, you know, that most startups have, it's around enrollment and enrollment numbers. And if you can, if there isn't a person that is that default recruiter, and no one really owns that or there's not the person that's like, oh so-and-so does that or so-and-so is like really good at that if that person doesn't exist

you know yeah it's not yeah you might want to rethink either the site or or like how do we how do we help and maybe it's too big of a lift right how do we help uh identify the right if this is truly a good site so yeah it's it's really really good point um i'm looking at the clock and i want to get to a few other questions here and and leave a leave a few minutes for the rapid fire portion of the interview but let's talk about fundraising right as a as a first time you know, CEO of a startup, like I imagine there's a lot you've learned, right, over the past, you know, four plus years now. But you recently closed on a pretty big round, right? I mean, a $30 million series C. That's super impressive. And I think you're what, all in? You're maybe

close to 40 million or so, like high 30s at some point. So a fair amount of capital into the company, by comparison, you're in an IDE trial. So maybe, I mean, it's, I would say you're pretty capital efficient, right? Getting to a, what appears to be a class three IDE trial. But all of that said, what do you, when you think about kind of everything that you know about fundraising now versus kind of when you first started Rivermark, are there a few kind of things that surfaced that's like, yeah, this is like, these are like the one or two things that I tell anyone that's starting a company that they really need to understand about about capital raising. Yeah, again, I'll put the disclaimer on. I've only done it once. I've only done it one way.

And we were very lean early on. And I'll give really Andy a lot of credit for that of, you know, he's the one really that said this is how much we should raise for the first round. did a $2.5 million round, which in hindsight seems like nothing. But we're able to do a lot with it. And it's like you've got to turn the dollars in into value. I mean, that's what the game is. So I think leanerly all was good. We've stayed focused on our existing investors and really keeping them in the loop and making sure they're happy. We've had great relationships with all our investors. We're very lucky at this point to be able to say that. And they've helped us raise money. So your existing investors can be a great way. Or if you're doing it again, like who was

your investor in your last company or a couple companies ago? So keeping that network of people up is important. For us, I think it was important to have two people that could tell the story. So there was me and there was Andy. You know, I had a co-founder. And I think the one-two punch was helpful for us. And maybe the most important thing is just positivity. It's such a challenging process. and there's there's so many negative just messages that you get as a founder trying to raise capital and I don't even it's just however you can be positive like exercise meditation prayer whatever you got to do stay positive and is that is very very hard and it's I've had days where it's like there's just it's just like existential dread and you just got to find a way

to get through it and I think for everyone it's probably different but if you come out with a positive message. I believe people appreciate that. Yeah. This topic doesn't come up enough. And I think if I remember correctly, I've only maybe touched on it, maybe in one other episode, this concept of being of being positive during the fundraising process. I think everyone that's raised money knows how difficult that that is in end of itself, you know, because it can just, I mean, it can crush you if you let it. But ultimately, if you're not bringing that sort of positive energy to the table, it's not going to come from the other side. So you do have to sort of find it, you know, and that's, that's just kind of part of the, part of the game. Yeah, it is. It can be

extremely, extremely tough. But yeah, I mean, your, your comment really around how to manage this sort of the roller coaster of emotions, it's, it's not for the, for the faint of heart, you know, by any stretch to imagine it, especially, especially for earlier stage companies. Yeah, I think there's a lot of headlines around the increase, you know, the positive signals in the, in the MedTac kind of venture community right now. But in the reality, it's like, it's a fair amount of money going to a few number of companies that are later stage and more de-risk. And so that leaves a big, a big hole, right, in these earlier stages, even with really promising technology, promising team, etc. God bless those investors that come in early.

I know, I know. They call them angels for a reason. I mean, that is, it's, that would be very, very difficult to be able to make calls. And, you know, you're, you're investing in the people, I think, more than anything. But even that's, it's just tough. So it's, I think, We sort of need more of those people in MedTech. Again, I haven't been around for a long time, but I think that is an issue, is that just the first couple million, so hard to get someone to believe in your story,

especially, I mean, if I was alone, I never could have convinced anyone. So I was, luckily, I was attached to a person, as a co-founder who had experience and who had credibility. And I've got that now, but I still wouldn't want to do something by myself. It's just, I'm just, I'm,

don't think I'm strong enough. I, I don't know. I mean, I don't know yet. I wouldn't want to do it alone. Yeah. It's hard enough with somebody else. Yeah, no, I hear you. It definitely helps with that kind of a co-pilot, if you will.

But I don't know. I don't know you that well, but I'm getting the sense that you could probably pull it off on your own, on your own, even if you had to. Maybe. It's that Midwestern, it's that Midwestern kind of roll up your sleeves, get it down and work ethic, right? So, yeah. Those are really, really helpful points.

Sometimes it's just, it's good to kind of think about more of those qualitative issues that come with fundraising versus, oh, this is, you need to have this in your slide deck and this needs to be kind of how you approach VCs, et cetera. But I'm right there with you, like, God bless the VCs that are still investing in those earlier stages, whether it's, whether it's institutional capital or angel groups, because you probably know folks that like, you know, demean traditional VCs, they're only sharks and you got to avoid them. And it's like, well, look, if we don't have. MedTech VCs in the space, there is no ecosystem for startups, right? Like you need them. And they've got to make their money too. And, you know, and any investment hopefully should be a win-win, right, both for the company and the VC, right? So anyway, we could probably go on and on about that particular topic. But before we get to the rapid fire portion, just one less question kind of around just, you mentioned it earlier,

kind of your early engagement with like reps and industry, right? And how that kind of almost fostered sort of even a greater interest in kind of the world of startups and kind of entrepreneurial stuff. When you think about, take us back to those days of like high volume, you know, urologist, you know, you weren't doing Rivermark at that point. Yeah. Anything that you think like industry could do better or maybe you wished, you know, you wished other device companies would do better as it relates to kind of just engaging with with KOLs. Yeah, I mean, I always thought of the reps as like a consultant. A good rep was like a consultant, and I believe the ones that do it well, they understand the product well. That's

like table stakes. I know, like, you know, how long is the scope or like, whatever. So you got product specs, but what you really need to know is what is the life like of your customers? So the physician's the customer, what's my day like? What do I worry about? What cases do I like to do? They don't necessarily have to know, like, what I do on the weekends? But I mean, what is my work life-like. If they have a deep understanding of that, that's the foundation in my mind of being a good rep. Now, as far as innovators working with KOLs and thought leaders, I guess the one, I don't know it's a criticism, but just I think an opportunity for them is to look a little bit beyond the KOLs and the thought leaders, those guys are super important and they're very smart and they speak and

they publish and they know the ecosystem and you absolutely need those people. But you also need to have relations with people that are ultimately going to use your product all day every day. And I'm sure people have said this before, but I mean, find that like Joe the plumber type of physician that's just rank and file going in, getting it done. And then if you can really find someone who's like that, but then also kind of gets the innovation, so the way the rep kind of gets the doctor's life, well, if you have a physician that sort of gets the innovator's life and things that they think about, those people are hard to find. And in my mind, one hack would be just ask the KOLs. You know, who would you recommend? So it's easy to find the KOL. That's the doctor that's on the podium and they're in the journals and they can see their name in their face everywhere.

They get contacted because they're very easy to find. But it's hard to find someone who's more like behind the scenes. But the KOLs know who those people are. You just say, hey, anybody in your network, give me two or three names, busy doc. smart guy or gal, likes to talk shop. They know who those people are. And I think that's, that, that, that, that, that, that, that, that will be a hack. So I don't want to tell too many people that. That's a good, it's a good. It's a good. It's a, it's a, because sometimes you can kind of get stressed out around, like, who are, who's that, who's that, the, the, the, the, the high volume user that still can kind of understand, you know, early stage, like device development, etc. But simply asking the KOLs, they probably have a few ideas. is, right? And that can just simply get the conversation started. But that's good stuff. So I want to leave a few minutes here for the rapid fire portion of the interview. But again, for everyone listening, rivermarkmedical.com is the website. Highly encourage you to check out

the company as well as the technology flow stint, Rivermarkmedical.com. We'll link to it in the full write-up on Medsider. But, Adam, with that said, I want to get to these rapid fire questions. Feel free to answer in short fashion. If you want to expand a little bit, that's perfectly fine, too. So first one on the docket, take us out to this time next year, 2012. Yeah, call it Q3 of what are you most excited about at Rivermark kind of at that point in time being done with enrollment enrollment's wrapped up submission to FGA is coming we're moving on to whatever the next phase is that'll be a good day yeah I can hear you all right since starting the company a little over four years ago now what's the most surprising or unexpected thing that you've

learned I've been surprised how much I've been able to learn about myself and what my limits are and the things that I like to do. I mean, I didn't, again, entrepreneurship was never really on my radar. And it's just been amazing. I think you got that from a lot of people. I've, again, very fortunate to have been thus far successful with it. But just what a tremendous experience.

A very pleasant surprise there. Not a stress-free experience, but a valuable one. Yeah, yeah. Those experiences where you're, yeah, where you're, you find yourself stressed a lot or oftentimes the times the times when you learn the most, right, about yourself for sure. So that's a good one. All right. Let's say we're in, in Milwaukee, maybe it's summertime, just wrapped up a nice dinner outside with a group of, you know, I don't know, 20, 30 med tech entrepreneurs. What's the one thing, like the one message

that you'd like want to leave them with that would be most maybe impactful for their kind of startup ventures? Yeah, again, I would, I'm a ways off from telling 30 med tech entrepreneurs what to do. But if I had the chance, we talked about this before a little bit, but learner mentality, I mean, so important, kind of that, that, that, that, that, that, that, that, that, that, that, that, that's, that, the learner mentality. That's, I think, any entrepreneur, not, not, not, not just med tech, you have to outlearn your, your peers. Yeah. To win. Yeah. That's, it's, it's, it's a mentality. Yeah. So the, the best entrepreneurs I know are not just naturally curious. They're always curious. Yeah.

I read a post by my buddy, Derek Herrera. I'm not sure if you know Derek at all. Yeah, he's awesome. He's awesome. And I'm paraphrasing now, but he mentioned the phrase that kind of stuck with me around cycles of iterations or cycles of development. And it's like, but that kind of that framework kind of applies to even learning, right? If you can out cycle in short sprints, learning a certain thing faster than someone else,

you know, that's going to create separation, right? So that's good stuff. All right. Last question on the docket. Take us back to maybe late 20. 20s, early 30s, right? Kind of wrap, you know, maybe at that point, you're in residency, maybe. I was going to pick of my residency.

Yeah, okay. Blinders on, head down. That's right. Getting the badge. Getting the badge. Well, anything you whisper in the ears of the younger, Adam, at that point? Younger me, I would probably say just be words of encouragement. I mean, that was a hard time for me.

Not a bad time, but it was hard. I mean, it was doing a lot of the same thing. I was stuck in a box. So I just think words of encouragement of like you're going to have your chance to grow horizontally. So I was very much in a vertical growth phase at that point. I'd just say stick it out. And then I think I did this. But then once you have a chance, think big.

And you hear there from a lot of people who say doing the small things as hard as doing a big thing. So you may as well do a big thing because it's a big win. I don't know if that's always true, but I think if you have the fire, thinking big is good, I encourage my kids to think that way. Don't underestimate yourself and try and do something big. Good way to wrap it up. And again, for everyone listening, thanks for your attention. You listen to best far. Highly encourage you to check out Rivermarkmedical.com. As I mentioned earlier, we'll link to it in the full write-up on Medsider. If you need these interviews, we do longer form articles that accompany the actual podcast episodes.

that are meant to like highlight and emphasize a lot of the key points that our guest share like like Adam just did over the past hour. So I highly encourage you to check that out. Adam, thanks a ton for covering out some time to do this. Really appreciate it. Thank you, Scott. I enjoyed it. Yeah, I don't have you hold on the line. But for everyone listening, as always, appreciate your attention until the next episode of MedSider Goes Live. Everyone, take care. Hey, it's Scott again. One quick thing before you go. You see, I love bringing you insightful conversations with the best founders and CEOs of medical

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