Medsider: Learn from Medtech and Healthtech Founders and CEOs - Why Curiosity and Persistence are Crucial Characteristics for Medtech Entrepreneurs: Interview with the Legendary Dr. John Simpson, Executive Chairman of Avinger

Episode Date: December 6, 2016

Dr. John Simpson.  Even if you’re a medical device newbie, you’ve probably heard of him.  He’s credited with inventing and commercializing the first over-the-wire balloon catheter used for percutaneous transluminal coronary angioplasty (PTCA).  This single idea created the field of interventional cardiology as we know it today. Over the course of his renowned medtech career...[read more]Related StoriesWhy Intersect ENT is an Example of Hope for the Medtech IndustryAre Medical Device Models the Key to Building a Lean Medtech Startup?Substantial and Sustainable – 2 Words That Medtech Companies Should Get Used To 

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they're giving it to our first 15 listeners for free, So go to reachfiredigital.com, forge slash medsider. Again, that's reachfiredigital.com forage slash medsider. Grab that blueprint. Okay, on to the episode. Dr. John Simpson, even if you're a medical device newbie, you've probably heard of him. He's credited with inventing and commercializing the first over-the-wire balloon catheter used for percutaneous, transluminal, coronary angioplasty, or PTCA.

The single idea created the field of interventional cardiology as we know it today. Over the course of his renowned med tech career, Dr. Simpson has founded and successfully exited companies like ACS and DVI, which were both acquired by Eli Lilly, CVIS, which was acquired by Boston Scientific, Perclose, which sold to Abbott, Lumind, which was acquired by Cortus, and Fox Hollow, which was acquired by EB3 and is now part of Medtronic. I mean, it's borderline exhausting just thinking about all of these companies, let alone starting them. Plain and simple, Dr. Simpson is a legend in the space, and he isn't done yet. He currently serves as the executive chairman of Avenger, where he and his team are developing a

portfolio of unique cardiovascular products aimed at solving in a challenging space of peripheral artery disease. In this interview with Dr. Simpson, we learn about the key lessons he's learned throughout his historic med tech career and why he's still fired up about medical device intervention after all these years. More specifically, here are the things we're going to dive into. How Dr. Simpson's infamous encounter with Jack Nicholas, yes, that Jack Nicholas, led to his firing as a bank teller, which eventually forced him down a new career path. The reasons why Dr. Simpson decided to pursue Andreas Grunzig's balloon catheter technologies and how it led to his own inventions. As a med tech entrepreneur, why knowing your strengths and limitations is key to making

a difference in the lives of others. We're going to learn more about Dr. Simpson's approach to building a team and how surrounding himself with people that have a broad group of skill sets has enabled his success throughout the years. The key challenges Dr. Simpson has faced with his new company, Avenger, and the important lessons he's learned. The advice Dr. Simpson would give to his 30-year-old self and how endurance through criticism is what ultimately leads to revolution within the medical field. So without further ado, let's get to the interview. Hello, Dr. Simpson. Thanks for joining the MedSiter program. Really appreciate you taking some time out of your day to engage in a conversation. Well, thank you. Thank for this opportunity. I'm definitely looking forward to it.

All right, great. Let's go ahead and get started. When looking at your, you know, your vast and storied med tech career, most people would assume, and rightfully so, that you've consistently had these sort of top of the mountain experiences, you know, time and time again. When looking at all of your successful med tech exits as well as just, you know, all of the products, interventional products that you've developed over the years, but it hasn't always been easy and even, you know, dating back to when you initially applied for medical school and didn't get in. So let's start there. Can you take us back to the late 60s and your infamous encounter with Jack Nicholas when you were working as a bank teller in Columbus, Ohio? Yeah, so thank you for that opportunity. This predates my getting ready

to go to medical school, of course. I just graduated from Ohio State University. And I was looking for a job. I was recently married and had a new baby on the way. And so I had no job. And so I applied for a bank teller training job at the Upper Arlington National Bank for Ohio State, or in Columbus, Ohio. And I was assigned to Telekate Number 4 and where the Jack Nicklose's secretary in 1967 came to Taylor, telekation number four to deposit his winnings from the U.S. Open. And the winnings were $30,000. If you can imagine that, you can look it up on the Internet.

I've looked it up. I can't believe it. But still, $30,000 or more made than I could ever have imagined. And the new teller in training, I took the check all around the Ohio National Bank, showed it to everyone until I got to the branch manager, and he took a damn view of me doing that. I said I had to get back to the teller cage, which I did. I put the check in the wrong stack, no computers, and they couldn't find it for about a month. And my teller cage every morning was out of the balance, $30,000, which was a little bit more than was acceptable.

Eventually, the manager came to me and he said, you know, John, I had to be. honest with you, I don't think you're cut out to be a banker, so I effectively got fired over leasing this check. And then shortly, well, not shortly. And 30 years later, I got a letter from Jack Nicholas said that he had heard this story. It was unfortunate, he said that, you know, my interaction with golf had led to a big change in my career path, but he hoped it had worked out okay. Such a great story on a number of different fronts, but I thought we'd start out with that, that sort of that funny anecdote, because I think it tells a lot about you and your, your background. But let's use that to transition to kind of just your general interest in cardiology.

Because correct me if I'm wrong, before going to medical school at Duke, you pursued a PhD in immunology and then went on to pursue medical school at Duke and then went to train at Stanford in cardiology. So, you know, treating cardiovascular disease, especially peripheral vascular disease, it seems like it's always been sort of consistent theme throughout, you know, all of the medical device companies you've started and really throughout your, you know, your career in medicine and health care. Tell us a little bit more about this disease and maybe, why you've always been interested in it? Well, I mean, vascular disease, of course, is the plague of our society.

And it results in an enormous amount of mortality and morbidity. And so I've always been interested in it. I trained at Stanford as a cardiologist. And all of my early work was treating coronary artery disease. But over time, gratitated a little bit more toward peripheral artery disease. Basically, just evaluated some new technologies. And we always evaluate the first at the perforovascular space before we take them into the coronary space.

Then through that, really developed, I mean, this is this fascinating observation, I would say, that, you know, I can fix somebody's heart vessels and, you know, they say, okay, great, I don't have chest being want to exercise anymore, doc, do you want to go have a beer? You save somebody from amputation, and it's totally different. It is like, you know, they expect to lose their leg, and then they do not. And it creates almost like a more rewarding experience, a culturally more rewarding experience, I would say, for the physician, for the hospital, you know, and for the nursing staff. You hear stories all the time about the nurses that are emotionally overwhelmed along with patients, you know, when they weren't able to avoid amputation. I think that's the thing that has created the allure of treating patients with PAD, but also PED is grossly underdiagnosed in this country. And I think I look at it as an opportunity to make something as profoundly impactful to the maldistribution, so I say, of patient care, accessibility in the United States. And if you're African-American, then you show up in the emergency room with a narrowed blood vessel in your leg.

There's two and a half times the chance that you'll have your leg amputated as if you're white. And there has to be, it's not all racism, but there has to be some racial components to that. There's some socioeconomic drivers to that as well. But it's just, this is so, you know, disturbing in a way. I just have always felt like it's a very, very exciting, challenging, a really, really important area to work in. And I think it has not really received the attention that it should have, and most of the attention goes to the coronary arteries. And they're very important, too, because you can definitely, you know, that's a lot more

mortality is associated with the coronary artery closing off than a leg vessel. But anyway, that's kind of my overview of PAD and why I think it's so appealing. Sure. No, I completely relate. I remember this is back during my days at Cividion before Medtronic acquired Cividion, but I do recall a presentation from an interventional cardiologist. And his name, his name is escaping me right now. But he was, I think I'm at the University of Oklahoma, but he was comparing, he made that exact analogy that you just referenced.

And he was comparing his treatment of peripheral arterial disease to coronary arterial disease. And he said, you know, oftentimes, you know, someone's left Maine and goes and sees them the next day, they don't, you know, they don't really necessarily feel any different, you know, or there's not really much of a response. But when he, when he saves someone's limb, you know, and treats them from a peripheral vascular standpoint, you know, they'll oftentimes give him a hug, you know, the next day. So he said it's just not much more rewarding. So interesting that you mentioned that as a component of kind of why you've always been interested in vascular disease, especially peripheral vascular disease. So cool. So let's transition to your time at Stanford.

And this sort of goes back to before you initially started developing angioplasty balloons. But in doing some research in preparation for this interview, it looked like you were almost ready to head to Jackson, Mississippi for additional training in cardiology until you sat in on a presentation from Andreas Grunzig. So can you kind of take us back in time and tell us a little bit more about that experience and how that sort of changed your career path at that point in time? Sure. I think maybe a better way to say it is that I was a cardiology fellow at Stanford at the time,

and you're always, as a fellow, you're always looking for a free meal, maybe a free sandwich. And I saw that there was a noon lecture and you get a free sandwich for this guy named Ben Dr. Grinchick was going to talk about putting a balloon into patient's coronary arteries, blowing it up, and they were going to get better. And I thought, right, I don't want to leave that for a minute. But I need a free sandwich. So I did that. I went to the noon conference.

Andreas was there, and he gave the talk about, you know, balloon antiphypastia to treat human coronary disease. And I thought, wow, I don't know, that seems a little bit crazy. And I told my wife that same day, I said, you know, I don't know, he's either going to revolutionize the treatment of astro disease or he's going to go to jail. And I sort of favorite jail is kind of the most likely. endpoint for Andres. But then I had a complication of Stanford, though, six months later, I didn't think too much more about Andreas's technology for probably another, say, four or five months,

maybe I had a complication. And I thought, gee, if I had that little balloon catheter that Andres was talking about, maybe I could have pushed this stuff that was in the arty that I had dislodged. I could push it back into the wall and ultimately convinced the chairman of the department, the chief of cardiologist Stanford, Don Harrison, to give me some time off to go to Zurich, Then to see Andres used some of his early balloon catheters, and I just thought it was just so magical. Came back, I ordered the catheters that couldn't get them, the balloons, exactly. So I ended up starting to work with Ned Robert, another cardiology fellow at Stanford. And we worked together who developed an end up and over-the-wire balloon angioplasty system,

we evaluated animals first, and then eventually it was good, it was safe, so that we could use them patients. And that was only out of desperation, it wasn't like I had any experience. experience the developing balloon catheters or, you know, even having a very good thought thoughts about how to do it. But I thought I could surround myself with people that did know how to do it and working together, you know, we could figure it out and we can end up making something good. Got it. And I definitely want to get to that last part of your answer there in regards to surrounding yourself with people that sort of allowed you to experience, you know, the many successes that you've had over the course of your career. But just as a follow-up question of that experience

with, you know, with sitting in on that presentation, you know, from Andreas Grudzig. You know, as I, as I, you know, as I heard about that, I read about that story and kind of thought about it. I think it'd be easy for most people to look at your career and think, you know, yes, Dr. Simpson, he's an entrepreneur. Of course that makes sense. He saw a need in the marketplace and developed a balloon catheter. But, you know, if I try to attempt to put myself in your shoes of that time, I mean, you're still a fellow. I got to think that this technology that Andreas Grudson was presenting is, you know, you kind of mentioned it. A lot of people were pretty skeptical about it. But you went ahead and sort of like dove that much deeper when most people probably would have just sort of moved on and thought maybe it was interesting and pursued a more a more traditional career path.

But you sort of went deep and began to sort of toy around with the technology. What do you attribute that to? Do you consider yourself sort of a natural tinker or just naturally curious? And what caused you to sort of take those initial steps to, you know, to go a little bit deeper with from a technology standpoint? Well, probably my brain is all messed up. So that's the best explanation for it. You know, I've had this question posed to me before. I really did not have a very good answer.

Somehow, to me, it seems like if you're presented with a problem, I don't know, it just seems sort of natural to try to seek out a solution that's better than what we're currently doing. I don't know if that's come from some of my graduate school training getting a PhD or if it's a part of my basic nature. I just really wish I could answer the question, and I'm unfortunately, I think my answers are always a little bit weak. but there is something about my nature that is like a persevering type personality if you will

and if I do find a problem particularly if I can see a way to what I think maybe it's just my own ego what I think could be a really really good solution and what if we could do this wouldn't that be helpful then I tend to kind of focus on that and then what if we could do this I usually I work on just trying to find a way to do it and that's really sort of the thing that probably separates me from some of the other physician entrepreneurs, I would say. I just keep just hanging in there until we figured out. I certainly wouldn't expect you to have sort of a, you know, the, the million dollar answer to that question, but I do think it's interesting to hear kind of get your take on, on that initial start, I guess, in that kind of towards the, the entrepreneurial

side of your mettech career. But on that note, let's kind of transition to some of your business accomplishes, accomplishments over the years. And I definitely want to get to Averger, you know, the company that you found in kind of the mid to late 2000s and where you're at now. But before we go there, I sort of want to set the stage for the audience that's listening that may be loosely familiar with your work, you know, and I would encourage anyone just to Google, Google Dr. John Simpson. You'll find a laundry list of different, you know, of accomplishments and successes along the way. But just to kind of quickly set the stage, I'll kind of run through some of these companies and then you can kind of, you know, correct me if I'm wrong. But I don't want to spend too much time

on some of your earlier, earlier med tech exits. But I do think they're interesting to note nonetheless. So, you know, advanced cardiovascular systems or ACS, as most people kind of refer to it now. That was your first company that you started back in, I think, the late 70s, which you eventually sold to Eli Lilly in 1981 or early 80s. That's right? That's correct. Yeah. That's correct.

Yeah. Something like that. The numbers may run together a little bit. But then DVI or devices for vascular intervention. That was a company where you initially, that sort of like started this interest in atherectomy. And you were developing atherectomy devices or devices to remove. plaque out of someone's blood vessels. Again, you sold that company to Eli Lilly in 90, and that

eventually formed sort of the foundation for guidance, which Abbott eventually, you know, acquired in kind of the mid-2000s. But DVI was to Eli Lilly again in kind of the 90s, right around 1990 or so. I think so. I think those were right numbers, but the important thing to observe there is that when we formed advanced cardiovascular systems ACS, we were able to put these little balloons in arteries, this all-treated coronary disease, and we'd inflate the blend, and sometimes it would almost be like a miracle occurs, and now then the problem is fixed, but sometimes it would not be a miracle, the problem was actually made worse, and when the problem was made worse, this was part of stenting. It kept going through my mind, instead of trying to just push it around with the bloom, what if it could actually clean it out? And so it was a natural transition for me, mostly because of the horrific outcomes, when it did not work well, when the end-spice did not work well, it really did not work well. And so we definitely wanted something to be better, and that's sort of the transition to go to something that cleans out the arteries. I guess that kind of speaks to what you mentioned earlier is you saw a problem, you saw a need. You said, I don't want to just simply inflate this balloon and squish the disease up against the vessel.

Well, I want to try to remove that. Why not try to get it out of there? And I think that kind of points to what you mentioned earlier and just try to solve a problem that you see, you know, that's very clear to you and may not be as clear to everyone else. On that note, with DVI, I mean, you obviously had a really good successful exit with Fox Hollow, and then now you're producing some really compelling devices with Avenger related to atherectomy. Why don't you think atherectomy took off with DVI back in the mid to late 80s? Well, it was very difficult to use.

The devices were long and the housing, so the way they were configured. Once you got them in place, I mean, they worked beautifully. But getting in place was very, very difficult. And also it was, you know, started competing with, you know, simpler and easier to use. technology with balloons and then eventually competed with stents and I think just ease of use was kind of the biggest problem for a DVI and and I think that was the concept though and we still see a lot of patients there's like 20 years out from being treated with the DVI device and they're already looks really well it's rare that I will go to the hospital and they don't say oh I have a patient

you have a patient 20 years out from the DVI and the artery still looks spectacular so when it worked well it worked really well a little bit like bullion and chip place see. But it was also very difficult to use. The concept was there. Maybe it was just the device itself needs some iteration, which we'll get to with Avenger and kind of what you're, you know, what you're, the portfolio that you're building out to treat perforovascular disease here in a minute. I kind of going through the other companies that you help to form cardiovascular imaging systems. Again, I think that that's unique because we'll get to it here in a second with your

work at Avenger. That was with Dr. Paul Yock, if I'm if I'm pronouncing his last name. I never know how to pronounce his last name. I've seen it so many times, but I probably never, never asked anyone that actually knew, but is that how you pronounce his last name? Yeah. Yes, that is correct. Got it. And then, and then let's see here, perclose, which is a femoral arterial closure device. You sold that to Abbott in 98. And then Lumen, which was acquired by Cordes in the mid-90s. And then in the late 90s, kind of leading up to where you are now, in the late 90s, you help start Fox Hollow, which again focused on etherectomy, as I mentioned before. And that was acquired EV3 in 2007. And then as most people know, Cividion acquired EV3 and then Medtronic acquired

Covidian, a lot of MNA activity over the years. But now in the bag of Big Blue at Medtronic. And then lastly, that kind of that leads us sort of to today, which Avenger, which is the company you're at now, which you formed, I think, in kind of mid to late 2000s, if my research is right here, which I see is almost a culmination of all of these products over the years, you know, from crossing devices to etherectomy devices to imaging devices, it's almost like everything that you've learned along the way you've been able to make iterations to are now developing an Avenger. Yeah, and I think that's probably the advantage that I've had.

This is one of the advantages to be a little bit older, unfortunately, but you have seen a lot of things happen, right? And some of you want to, you also, you always want to make it better. But in the very early days of angioplasty, I thought, you know, we needed something to clean the vessels out, and started DVI, and that's something that cleaned the vessels out. But you could not always aim it in the direction that you wanted to base system on the x-ray, images. So we talked about adding imaging to this and Paul Yock, part of the motivation that we had with Paul Yacht in cardiovascular imaging systems was to add intravica ultrasound to the imaging catheters, which we tried to do, but it just turned out that it was too hard

to do at that time because the technology just did not exist. Along the way, we were in that era also were putting in some early stints and we ended up with bleeding problems in the groin because these patients were like coagulated. And so we started perclose to close these holes for for arterial access sites. And that was really, you know, it's a little bit of a deviation, let's say, from the theme that I've used mostly, which is to treat neurod arteries, but eventually that sort of back on the treat the narrative track with Fox Hollow and really great device, but limited because once again, back to the deviant era, you cannot really rely as much as you would like to

on the x-ray images to tell you where to cut. And Paul Yacht pointed this out to us really in the early days. He said, you would like for these deposits to be really concentric and they're not. And by interest ultrasound, you can see that they're not concentric. You can see which side to aim your devices out. And so Fox Hollow had that limitation, and although the device had worked well, sometimes you would cut too deeply into the already wall. And when that happened, then you had the risk of some extravasation locally of contrast,

or you would have higher recurrence rates. And it led to back to the theme of, you know, if we could see, we know that removing the plaque is really, really favorable. If you could remove just the right amount and the right spot that you wanted to, then that could be the end. answer. And I think that's what Avenger has embarked on, developed a lot of technology around imaging using optical-reherence tomography as the imaging system, which is a laser-based system that allows us to look at the artery while we're working on it. And it really creates

a remarkable safety profile, as well as efficacy profile, saves physicians from excess radiation. So I think that is, in a way, you say the culmination of all the efforts, maybe so, but culmination just sounds like the end. So I don't know if I've really. like that term, but they did what it is, right? Yeah, yeah, yeah. No, I couldn't, that's the word I came up with, I guess, but certainly don't want to, don't want to depict that you're at, you're at the end of, you know, putting a book end on this particular chapter anyway, but, but in terms of devices themselves, it certainly seems like, you know, your career has kind of led up to this point where you're, you've been able to iterate on a number of different devices that you develop over the years. And,

you know, here we are with, with, with, with Avenger. I want to ask you a few more questions with respect to Averger, but just kind of going back to, you know, all of these companies that you've started in the past. You've always been able to surround yourself with, you know, with a great team. And you even pointed it out earlier in the conversation. You know, people like Ray Williams and Bob Reese at ACS, Allen Will at DBI, Hank Plain at Proclose. I'm just mentioning a few names that most people would probably be familiar with. But, you know, the list certainly goes on and on. So, you know, for those people that are listening to this right now that would consider themselves, you know, med tech entrepreneurs, whether they're physicians themselves or just entrepreneurial in nature.

What's been your approach to building out that team? Is it always come naturally or is it been by intention that you've sort of sought after people that, you know, bring different skill sets to the table. Talk to us a little bit about that. Yeah, I would say there's a sort of a harsh reality is that, you know, all of the people that you've just identified were introduced to me by someone else. And they said, you know, you ought to talk to, and Ray Williams is the best example. No, actually, that's not quite true. I met Ray Williams when he was a parking lot attendant for the circus club, what's it called? They have the horse riding show at the circus club, and he was parking cars and his wife was on the committee that ran the show. And he said to me that he had heard

about what we were doing with Blenangioplasti. He was interested in it and why don't I give him a call? And he said that he does a lot of venture capital work. And I had never heard of the term venture capital before. I had no idea what that was. And so I never called it. And then finally one day he called me back and you said, gosh, you know, I thought maybe you would have called me back, you know. And, you know, I had a lot of people looking for funding for me. It didn't sound like you needed it. And I said, well, we always need it, but I don't know how to do it. And he did. And he said, well, I'll do it.

And he did. And then he was the one who hired Bob Reeves at ACS. I mean, he's just a fascinating litany of and wonderful people that I've been involved with. And I don't have any idea of all to kind of took place. A lot of times just by being introduced to somebody who knows somebody, I don't think I've ever done it like a, you know, like a real search and found somebody that I wanted for a position that's usually. I'll ask a friend. do you know anybody who could do this? And they say, oh, yeah, why don't you ask so and so. That's been, I think, a better system for me, but a lot of people rely heavily on searches to find. I do that

through my friends and my acquaintances. So now then I have enough friends and acquaintances that I can cheat a little bit. Certainly your network's broad enough and you've had enough accomplishments that along the way that I'm sure people would be more than willing to try to, you know, be a part of your team or at least help someone they knew that, you know, to be a part of your team. But, you know, Let's go back to where you're at with Avenger. I know you mentioned a little bit about kind of the broad peripheral vascular portfolio that you're building out now and some of the unique aspects of your products. But, you know, I think a lot of people would have looked at maybe, you know, after exiting,

having a nice exit with Fox Hollow to EV3, you know, considering all of the previous accomplishments that you've had, they would have said, you know, Dr. Simpson, it's easy for you to go right off into the sunset, you know, and most people would, you know, clap their hands and give you an ovation and say, wow, what an amazing career. But you haven't stopped. You know, you went on to form, you know, Avenger and for sort of a, trying to find a better word for culmination. It's sort of a, you know, the next step, you know, sort of a lot of these different products. You know, what do you, you know, what's the, you know, is there something that kind of, that causes you to keep going and, you know, starting these companies?

You know, what's the, what's the sort of the, is there a burning challenge that you're, you know, you're trying to solve for, you know, an Avenger that, you know, keeps you, keeps you going. Well, I think I do you have the additional advantage of being able to see the patients and see in the misery. that these different diseases cause, a combination of an entrepreneur and a physician. And I don't think I've ever lost sight of that, that how miserable these diseases are, you know, if there's an opportunity to build out a system that would reduce this misery and the suffering, I mean, when you've seen patients that are about to lose their leg or the patient in the QDMI setting in the coronary care unit, you just want to help them. It's very motivating.

It's not like you're reading about some kind of a science book. I mean, this is real. And if you work hard at it, you know, then you can make a difference. And that's always the way I have sort of approached it to make a difference for the patient. I'm not, my strength is not business. I definitely surround myself with people that are really good at it. But, you know, that's not my strength. My strength is more clinical. And then maybe a tinker is the right term. I just, I do sort of like to, I don't know, figure this out. I don't know. I'm not making any sense at all now. No, no, I think, to me, from my perspective, it makes a lot of sense. I mean, you sort of know not only your interests, but it seems like you know, you know, where your limitations are as well.

And you know when to, you know, ask the question of like someone that can, you know, serve in this capacity or can it can help me meet this certain need. I think that's a good lesson learned for any med tech entrepreneur out there is, you know, could have, you know, be cognizant and be, you know, acutely aware of sort of where your wheelhouse is and where maybe your limitations are. And, you know, don't be afraid to kind of ask for help where it makes sense. That is one of the things that I feel like that I am pretty good at is knowing I know what I'm good at and I know what I'm really bad at. Unfortunately, the list of what I'm really bad at is pretty long. What I'm good at is actually pretty short, but I've told a lot of people that if you let me get inside a blood vessel, then I've got you. You just go to be really hard for you to beat me inside a blood vessel. You give me a P&L or a balance sheet or something like that and you have me.

I will be clueless. So that's why I have to hire somebody else to do that. Yeah, no, it's a really good lesson. I think it's one that sounds simple when people describe it, but it's somewhat, you know, when you're in the trenches, knee deep and in the work, sometimes it's hard to let go, you know, and not acutely aware of like when to hand something off. So obviously maybe it comes a little bit more naturally for you, but maybe more challenging for other folks. You know, the other thing that I thought was interesting that you pointed out there too is just and granted, you're a physician, you're a cardiologist, but also just that natural bias towards

the patient. And I think that's, that's one of the unique benefits of, or advantages of being involved in MedTech or healthcare is that unlike other tech companies there in Northern California, you know, Facebook, Apple, Google, et cetera, not that those aren't great companies, but, you know, there's always sort of a, the benefit to being involved in med tech is that, you know, you're working on devices that are being used in, you know, on a daily basis to treat patients. And so I think that's always, it's always kind of a nice aspect, especially when you can, when you appreciate it. And it sounds like obviously you have over the years. It's hard to avoid. And if you know that, and I, I do know a lot of people, a lot of engineers that can make these things better, and I rely

on them to do that. I'm a little bit like the quarterback and a football team where the team is really great, but it's only because of the linemen and the receivers and the running back. It's not because of the quarterback. And yet the quarterback gets way, way, way too much credit. I sort of feel like I'm in that situation. I get the credit for all the work the engineers do, the assemblers. I mean, the assemblers are putting together stuff that's like it's miraculous, and yet I get

the credit, which is totally wrong. I think you're being humble, but I think most people would appreciate that comment, though, for sure. And to your point, definitely without a doubt, it takes a strong team and a strong quarterback or leader to kind of move the team forward. You know, kind of going back to, you know, what your experiences over the past eight, nine years or so with Avenger, you've certainly been able to take a lot of experiences with you along the way. So, you know, thinking about Avenger and what you've experienced over the past, you know, the past, you know, three, was it, three decades or so, Are there certain challenges that have come up at Avenger that have surprised you?

And then maybe on a similar note or in a similar vein, as you've approached some of those challenges, are there some key lessons that have sort of helped you, you know, key lessons from the past that have sort of helped you during some of those more challenging times at Averger? Well, I will say that the challenges that have surprised me with Averger, a little bit different than some of the previous challenges, is the difficulty in this modern era of raising capital. We can always raise capital. He's like a little bit more easily. Maybe he'd go back to Ray Williams and have him put us to start that over for us again.

But he was always really good at it. I feel like that in their current era, and I don't think I'm speaking just Ravanger, I think, across the board. People are investing a lot less now in innovation at the early stage. There was a time when everybody wanted to invest in that. That's no longer the case. They want to invest in a large revenue stream. We like to invest in profitable companies. I've never had one of those.

I don't know what that would be like. but I would say that it's just different. And some of this stuff would be, to me, totally unanticipated. That being said, some of the physicians are under such enormous pressure from their hospitals that do cases to, you know, just do patients to have increased patient volume. But they may not be so interested in learning a really new and innovative technology that probably can give better results, but it's going to take more time. And there would be resistance to that.

I see some of that right now. I find that a little bit shocking, never occurred, you know, maybe one. when I was a little bit younger and practicing medicine daily. I just, I can't see that approach. But it is, it does exist. But I think the overall lesson is still is about the same. I mean, regulatory fairs are still hard, but just persevere. I mean, you know, the FDA, you can eventually,

if you have to just provide the right data once you do, then eventually everything will be approved. Now, just perseverance is really important to raising money because everybody you talk to almost always will say no. kind of keep working at it. And that's the way I would probably characterize it. I don't think, I mean, Averger is trying to do something has never been done before. And Averger is actually doing something that's never been done before.

It's mounted almost like a camera on a cutter, and you can see what you're cutting without an extra it. Never been done before. That means that it's hard. That also means that suspicious. And people would say, oh, you know, that's never going to work. You know, Simpsons tried to do that forever, and that's just not going to happen. So I think, you know, you have these prejudices and biases that are in the market, the physician community and the investment community.

You know, just have to overcome them. And, you know, we did a lot of that with the early days of Blenantiaplasty when the surgical community, this was an uproar. I was a cardiology at L at Stanford. You know, the faculty at Stanford would come by that the way they started that morning off every day to make them really happy was to come by and laugh at what I was doing. So it was eventually, sometimes that's motivating, right? You know, what's this? I'm going to show them. So anyway, I'm digressing from your original question, but perseverance is the key, and raising capital is the current impediment in my mind.

Sure. Yeah, no, no, that's it. I really appreciate that answer. And I think, I mean, sometimes it's very easy to underappreciate something like that. And I liked how you put it, you know, just know that it's going to be hard. It's going to be difficult. I mean, like as an example, just like you mentioned, you know, with Avenger, you're trying to put a camera on a therapeutic device, you know, so that allows physicians to see what they're treating and also treat at the same time. So, I mean, something like that, that, that's something like that, that. It's definitely an engineering feat, but yet you're still able to do it in today's climate, you know, when so many people would lamb in and complain about, you know, how hard it is to raise money. And I like your approach and just know that it's going to be difficult and know that there's going to be times that you're going to have to persevere through those challenges. That's a great anecdote and something that I think a lot of us need to hear again and again.

I think that's the case. It's about how hard are you willing to work and how committed are you to the project? Yeah, easy to understand, but yet yet hard to sort of implement and execute on for sure. But on that note, before we kind of wrap up with the last three rapid fire questions, anything else that you think that would be good for the audience to know, whether that's about med tech entrepreneurship in general, about cardiovascular disease or, you know, what you're doing at Avenger, anything else that you think is worth sharing? I think we've covered it in a good detail.

I would like to add that anything that anybody who's listening can do to increase the awareness about how serious peripheral disease is and how important it is to get early diagnosis in treatment, almost like cancer, if you will. There's anyone out there that can help do that, then that would be wonderful. It's a huge problem. Sure, definitely can appreciate that. It's one of those, most people, you know, fairly easily understand coronary arterial disease, you know, because you understand, you know, when people think of stents or something like that, they think of, you know, stents in your heart, but people are pretty unfamiliar with, you know, perfor arterial disease because, you know, it's not something necessarily that, you know,

you're going to die from immediately, but at the same time, it's severely underdiagnosed, as you mentioned before. So, very good. So let's, let's, let's, uh, let's quickly kind of transition to the last three rapid fire questions. The rapid fire, just in, in nature from a question standpoint, but don't feel, don't feel like you have to be, you know, rapid fire answers. You can feel free to expand if you expound a little bit if you want. But the first one is, what's your, your favorite business book? Well, I'm not, I see, I'm not sure you would, I think it's a business book. So Malcolm Gladwell's outliers. It talks a lot about, it takes 10,000 hours to be good at anything. I think, that's probably an understatement, unfortunately, for Malcolm. I think it takes more than

10,000 hours. But I think that that's, oh, it's just a really cool book. And to me, it just talks a lot about it. And I think probably it is. The theme there is perseverance, which maybe just fits my basic nature. Yeah, yeah, definitely. Let's see here. The second question is, is there a business leader that you're either following right now or maybe one that's inspired you in the past that you sort of naturally gravitated towards? Well, for sure. I mean, you may I consider my business leader. To me, he is a business leader. He's also a really good surgeon.

His name is Tom Fergody. And Tom, without Tom, I would have never been able to do anything because he was the surgeon that supported me at Sequoia Hospital locally and just absolutely amazing guy. I mean, grew up in a huge family of the Appalachian Mountains and vetted the motor scooter clutch. I don't know. He is the ultimate inventor. And I think, I am not.

I'm the kind of the worker bee that just keeps plugging away until we get it right. He has a different approach. I think Tom Fogarty is just a huge, it was a huge factor in my life. And, you know, with that, and we had to be willing to stand by and bail me out of trouble. And unfortunately, Tom called him a lot to bail me out of trouble. So, but I admire Tom because, you know, he's built, you know, certainly more, a lot of businesses and just such a really, really magical stuff. And I think he's just a huge, a huge factor in driving the way vascular disease is not only treated, but also. diagnosed. Yeah, it's funny. I remember the first time I met Dr. Fogarty is this is when I was at

at Cavidion again. And I think I was at a medical meeting of some sort. I can't remember which medical meeting it was, but we were displaying the trellis device. I'm not sure if you remember that that device for, yeah, for DVT or D. Yeah, yeah, exactly. But I remember, I think it was at one of the, we were showcasing the device at the booth. And sure enough, he was there and he walked up and sort of introduced himself as the inventor of the device. And I think a lot of the people around me were, you know, thought he was joking. But I was like, no, no, he really, he really, he really did invent this device. So just kind of funny anecdote. It probably speaks to his personality. But very cool. Lastly, we'll kind of wrap it up here. But when thinking about your, you know,

your med tech career, tons of accomplishments, obviously a lot of challenges the way, but you've really pushed through and had a lot of really great accomplishments. Is there one piece of advice that you tell your 30-year-old self if we had the opportunity to sort of rewind the clock? Not 30-year-old self. That would be, yeah. You know, I don't know that it's anything different than we've sort of already stated. I mean, I think that you have to be willing to endure a lot, and then you have to be willing to persevere. And being willing to endure is sometimes the most difficult part.

Now, sometimes think about the pathologist at Duke University is kind of a philosopher, too, who wrote in some article that, you know, anytime you develop something that is incrementally an improvement in medicine, there's a huge applause, and everybody congratulates you on this really wonderful. Well, if you do something that is really transformational in medicine, then you'll have a lot of criticism. Everybody will find fault with it. You know, if it's revolutionary, they would, you know, it will be absolutely criticized. And so I think I've focused more of my attention on trying to do things that are revolutionary in a way.

And so there will be a lot of criticism that comes your way. But what you want somebody to conclude at the end of what you've done, and they look at it and they say, you know what, these are signs that you would associate with a revolution. And that's been my kind of goal, I was supposed. Yeah, no, that's a great, I think a great way to sort of wrap up this conversation. So I'll have you hold on the line here, Dr. Simpson. I can't thank you enough for joining me in on this conversation. And, you know, for those, I get all linked to it in the show notes online.

But if you want to go check out Avenger, just go to A-V-I-N-G-R.com, Avenger. And otherwise, just use Google. Avenger or Dr. John Simpson, you'll be sure to find his current work. Thanks again for your willingness to have a discussion today, Dr. Simpson. I'll have you hold on the line. but just wanted to express my thanks again. Thank you.

Thanks again, ladies and gents, for listening. This episode has been brought to you from the WCG Studios here in Minneapolis. And don't forget to grab your Panoptic stacking blueprint by visiting reachfiredigital.com for slash medsider. Again, that's reachfiredigital.com forward slash medsider. Okay, bye for now.