Neurosurgical Entrepreneurship Free

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- So hello colleagues and friends. Thank you for joining us. This is our first workshop on Atlas Innovation. We wanna welcome those residents and the colleagues who have been invited to be here today. I'm going to give a brief presentation of the Atlas as we know it today and where we are going, and then move on with our speaker today. My name is Aaron Cohen. I'm the president and founder of Neurosurgical Atlas. So I'm going actually introduce Dr Forcht Dagi. Teo has been a dear friend. He's one of the most worthwhile and valuable thinkers in neurosurgery I've ever talked to. He's the professor of neurosurgery at Mayo Clinic at this time. He has numerous, you know, affiliations with many very respectable organizations in Europe and the United States, and he is really positioned as a thoughtful leader and innovation in neurosurgery is unparalleled. Before we start with Dr. Dagi, I'm gonna go ahead and just briefly describe the Neurosurgical Atlas as we know it as a change in the order of things. Most of you know Neurosurgical Atlas as a nonprofit organization, which has great videos, chapters, images, illustrations, and we've been really blessed to have over 75,000 members, over 3000 members coming to see us on the web every day. And really, it's been an incredible project and it's become almost a bible of cranial surgery, which is a big honor. Our viewership has been tremendous from all over the world. Our donors have been tremendous to make this possible. Recently, we were awarded the Vilhelm Magnus Award by all the Scandinavian countries, which is really almost as valuable as a Nobel Prize in neurosurgery since there is none in neurosurgery for, as a Nobel Prize specifically. I'm gonna go ahead and ask Dr. Forcht Dagi to enlighten us with his lecture on the topic of neurosurgical innovation, which I'm so excited about. Teo, very honored to have you with us. Please proceed.

- Thank you very much. I'm very honored to be here. If for no other reason, and there are other reasons as well, it's because Neurosurgical Atlas is a perfect example of what we're talking about in terms of neurosurgical entrepreneurship. It tries to give a complete solution to a problem, and the problem is how do you find, how do you archive, how do you convey, how do you teach information? How do you take information and convert it into practice? Now that may not be the way in which the program Neurosurgical Atlas has started, but it is what Neurosurgical Atlas is. And so what you see when you look at Neurosurgical Atlas and the work of Dr. Cohen-Gadol is exactly what you have in entrepreneurship, problem solving, and then a product, and then moving the product to the point where it does something very important in the market. And what I'd like to do is to give you a very short course today. Much of the material that we have here was incorporated in the Harvard MIT program in biomedical entrepreneurship, which I helped run for a decade or more. And it tried to incorporate and to integrate material on how you become an entrepreneur and what that means. So let's start with that. So entrepreneurship has a bunch of standard definitions if you look at them. Standard definitions focus on founding and running a business. Well, we're not necessarily talking about running a business, although it may be. The point is the entrepreneur is the individual who's behind it, and assumes the greatest risk associated with the project, risk of time, reputation, investment, money, in return for reward. What that reward is is up to you. For some people, the reward is having the product, an artist, for example. Somebody I spoke recently to somebody who spent his life engraving coins, and for him, the reward was the actual coin that he had in his hands, but it could be the actual wealth reward and it's classically expressed in terms of market disruption. That's actually too narrow a view. Entrepreneurship in the neurosurgical and in the scientific world is linked to targeted innovation, to disciplined risk, to personal investment, and therefore, to market disruption and rewards. So let's go through some useful terms. What is a market? A market is everybody and everything that can use a product or a service. It's as large as you can make it. It turns out to have a monetary value because in economics, most things can be expressed, embodied in monetary value. The reason this matters is that ultimately the maximum value of almost any enterprise is denominated in terms of the maximum market size. So many neurosurgical businesses, for example, products end up having a value that's denominated in something like 150 to $300 million because that is a typical annual revenue for a successful neurosurgical device. If it's less, the business will be worth less, and if it's more, say spine, it'll be much more. And if it's diabetes or cardiology, it may be worth in the billions. The unit economic model is the way you think about how you get people to use, acquire, and pay for something that you've built. So it could be online, it could be virtual, it could be on a per click basis. It could be that somebody buys it, in which case you ask, well, who sells it then? How do you persuade them to buy what it is? And I use the word 'buy' because ultimately, you need an exchange of value for an enterprise to be successful and that's called the revenue model. The revenue model is how the enterprise makes money. Now, you as an entrepreneur may take part of that. If you have a company that's gone public, you'll have a much smaller part of it than you've if you own all of it. But the revenue model is ultimately the reason that people do this. The sales model is how you sell something. So for example, it's generally said that the United States in neurosurgical terms is divided into the northeast, the middle Atlantic states, the southeast, Texas and the areas around Texas, the Midwest, then the northeast, and then the southeast. And if you were going to sell a new device or a new instrument or a new drug, you probably wouldn't sell it across every area at once. You'd probably focus in a place that you know well, where you understand the dynamics of what people are looking for, and that's where you would start and gradually brew what you did. That's the sales model. And then there's the exit strategy. Let me go to the next slide to talk about the exit strategy because that has to do with the type of entrepreneurship that you're interested in. There are four kinds. The small business enterprise is, you are one of the people who 50 years ago, in your basement, built an aneurysm clip. It's a great aneurysm clip. You sell it because people know who you are, they trust you. If you have an aneurysm clip, it'll work, and so, they buy it and they try to do it. It's a cottage industry. Eventually, you'll have to make a decision. Are you going to run it forever or are you going to sell it to somebody else, take your profits and go do something else? If you're going to sell it to somebody else, which is what most people do, then it's a cottage industry with an exit. If you're going to be hanging onto it all your life, then it's not. Now a scalable startup enterprise grows into a large market, and then you have an exit. So let me give the example of Dr. Rontgen and Rontgen's Instruments. Dr. Rontgen designed and he may have actually built some of his own instruments to begin with, whether he was working on a lathe, but he worked with people who were on a lathe. And sooner or later, it was acquired, the line was acquired and the Rontgen Instruments are now known can be acquired any place. Same with the YASARGIL clips, the Heifetz clips, any number of other devices, there has to be an exit. Social entrepreneurship is something completely different. Let's say that you want to build an enterprise which is around the rehabilitation of people with stroke. And let's say that you want to work with memory neurons, which means you believe that people with stroke can recover up to two to three years rather than just 30 or 60 days or one year after a stroke and you build a foundation to do that. You gather money for it, and eventually, you sell subscriptions to it and you sell instructions. Well, that doesn't have to be for profit. You can put the money back in the foundation. In fact, in Indianapolis is a very, very famous foundation of that sort. Steve Isenberg, whom you may know who's an ENT surgeon, just retired from the university and had a private practice, decided that he was going to give his medal, his own personal medal as a runner to children with cancer and started a movement in which children with cancer and also other people who went through difficult times for health reasons, were given medals by people who won marathons. It was called Medals for Mettle. It's a fantastic enterprise. He's never taken a penny out of it, but in terms of entrepreneurship, he had to go through all the same kinds of things. Large company entrepreneurship is something different. You may have, for example, a relationship with one of the large companies, any one of them, I don't want to mention names, you all know what they are and they come to you and say, "Gee, you are using a lot of shunts. You've told us that some of the shunts fail. Can you design a better shunt?" That would be an entrepreneurship involving a large company. And if you know an engineer who works for that company, well, perhaps you'll partner with that engineer and the engineer will be the 'intrepreneur', inside the hospital and you'll be from the outside, the entrepreneurship, I said hospital, I meant company. The entrepreneur will be precipitating the changes that are done. And sometimes, these are called 'skunk works'. 3M's a company that actually was owned in part by a neurosurgical family and they had a lot of skunk works. In fact, Post-it notes came out of skunk works outta 3M. What's the approach to a new product or a new idea? First of all, assume a problem solving approach. It's an engineering approach, not what do you want to do as much as what problem do you wanna solve. And focus on a market-based problem. If it's only your problem, maybe great for you, but probably will not succeed for other people. So a Non-Stick Bipolar is a market-based problem. A Bipolar alone, a new type of Bipolar perhaps, or making the lips of the Bipolar just a little bit thinner probably that's not a market-based product today. It would've been 50 years ago before Malis. Identify an idea. The idea of a Bipolar, for example, was the idea of restricting the coagulation current to a very, very small and manageable area. Connect the idea to solutions. In the case of a Bipolar, you needed to have a generator for bipolar current, you needed to have an instrument, you needed to decide where it would be insulated and how it would attach to the generator. You needed to figure out whether it could be cleaned because if it couldn't be cleaned, it had to be replaced. So how do you do that in the operating room? You had to figure out whether it was going to be sprung. If it was going to be sprung, what was the standard for the spring so you could open and close it as many times as you needed to in an operation without fear that it was going to break? How is it going to be sterilized? How is it going to be packaged? How is it going to be sold? What about the generator? Does the generator have to be regulated? What if it breaks? Do you replace it? Do you repair it? On the spot or do you need to send it in? These are the kinds of things that go into a solution. Then you need to develop a business case and we'll talk about that in a second and then you need to write a business plan. So the best book I've ever seen on business plans, it's called "Business Plans for Dummies". Please don't laugh at me. Actually you're welcome to laugh at me. It's written by a very interesting guy who actually predicted and did studies on the steel industry in America, and made himself into a fantastic consultant on steel and other things. He happens to be related to both the Tiffany who was the artist and the Tiffany of Tiffany Stores. And this book, which he wrote almost as an afterthought because people kept on asking him as he was teaching in a number of business schools and consulting with his CIA, how do you start a business? It happens to be one of the best books ever written in business. And so, if you don't mind the title, use that as a reference. There are plenty of other ones as well, but this one is particularly good. So you start with an executive summary. The executive summary is a little box. It tells you what you're going to be talking about, and it outlines for an investor, maybe a venture capitalist, maybe a company that wants to invest in you, what you do. Then you have a description of the company. How many people are in it? Where is it? What does it do? Does it manufacture? Does it package, does it design? Does it expand? Can it enlarge? Can it scale? What are the products and services that it gives? One of the great examples of an answer to that question is Kinko's, the copying people. Kinko's and FedEx got together and the problem was how do you put Kinko's and FedEx together? Well, they're about communication. They're about transmission of information and they found a way to do it so that each reinforce the other. Then you need something called a market analysis and a competitive analysis. Let's say that today, I came to you with a brand new Bipolar, and let's say I called it The Brand New Bipolar. First thing you're going to ask me, how much does it cost? What's the marginal advantage over what I already have? Why should I buy this? Why is it better? Who else is making something? And then before you would buy it out of your own pocket, you would go around at a meeting and look at all the Bipolars and finally decide this Bipolar is for me because, and that because is the competitive analysis. Sometimes people say competition represents people who want to eat your lunch, and competitiveness is what makes your lunch worth eating. So what is it that you're going to build or design or create or think about that other people are going to want because they can use it or because it'll give them some kind of advantage or because it'll perhaps fill out their instrument line or their market presence. Then you need a plan for marketing, which is how you're going to promote it. What are you going to say? It turns out the FDA has a lot to say about that. If you say this Bipolar instrument can be used to stop bleeding anywhere, FDA will say no. If you say this Bipolar is designed for, and you say specifically what it's designed for, the FDA will work with you. One of the famous examples of this had to do with the introduction of lumbar screws for the lumbar spine. The initial ones were restricted to a very particular segment. The double ANS had a course, and the course said, well, I know it's allowed for this segment, approved for this segment, but you can actually use it in many segments, and they got a Whoa, Nelly warning. The indications were not the indications that were approved. So you have to figure out what the market is actually going to allow you to do, in this case, the FDA. How will you sell it? Will you sell it at a meeting? Will you have salesmen? Will they go to individual surgeons? Will they go to a hospital? What's your revenue plan? How are you going to price it? What kind of profit do you need? When does the business become self-sustaining? And then what if you want to grow it, and when do you bring in other products? What is the management and organizational description? Are you going to be the CEO, or you're gonna find the time to do that? If you are operating and you're trying to do 500 cases a year, even 300 cases a year, where are you going to find the time to run an enterprise? You're gonna to have to answer that question to investors whom you want to give you money to grow the organization. What's the organizational description? Are you going to have a chief operating officer? Are you going to be talking to the outside and the chief operating officer will deal with the inside? Who's going to do your books? Are you gonna have an accountant? Full-time accountant? What about the salespeople? Will you rent the sales force from an organization that has its salespeople who are paid on commission or you're going to hire your own? What are your financial projections in need? That's going to require you to think very carefully about the stage of the product. Is it ready to go or not? What is it going to take to scale up production? What is it going to take to go to the FDA? What is it going to cost to do clinical trials? When you have to change something because of the FDA, and everybody always does, what is it going to cost? What kind of monies do you need? Very important not to run out of money in the middle of an enterprise. And what are your financial needs for the company? Do you need a big building? Can you work out of a tiny office? Do you need a receptionist? Can you do it online? Who's going to answer questions? Can you use AI? Are you going to have doctors that you're going to work with? Are they going to be your friends? Can you pay them in stock or they going to be asking cash for help? Then you need an operating plan. I'm going to put this company in Minneapolis because there are a lot of medical device people in Minneapolis. I'm going to put it in Boston because I want biomedical engineering, and then I'm going to put it in Ireland because in Ireland, there's a great medical device hub and that hub will pay me to actually locate a factory in Ireland, and for a few years, will take care of my taxes. And at the very end you'll have to look at yourself and say, what do I want to get out of it? Do I want to run this, as I said earlier, or do I want to exit it and go on to the next thing? And that's called the exit plan. And then you need an appendix with supporting data. You tell me that you have a shunt that is not going to get blocked with proteins lower than, take some number, whatever number you want. How do you prove it? How do you know how easy it is and what's the chance it's going to migrate? You tell me you have a shunt that's not going to migrate, I believe you. That's wonderful. Show me. What's the proof? You tell me you have a shunt that's impregnated with an antibiotic and it's not going to get infected, really? Show me. What are the statistics? How is this better that exists in the current market? You have to be able to prove everything that you say. Before you start a business, there's certain requirements. First of all, you have to own the invention. If you are working for a hospital, an institution, or an ACO, if you're working for a university, you may not be in a position to start a business without licensing the property away from the organization that you work for. Most organizations have some kind of intellectual property clause that says, "You work for me, I own what you make." Now in some cases, in Germany, for example, at the University of Heidelberg, they've suspended that. Some institutions like Stanford and famously, MIT, are very liberal in what they let you do. Others are very, very restrictive. And the difference between being on one side of the river and Boston, the Harvard side, and being on the MIT side, is that at Harvard, it's very, very difficult to start a company. In MIT, it's very easy to start a company. Within the same city, same culture, there can be real differences. Then the competitive analysis. The competitive analysis says, I make a widget, I make a product, my product does the following. It is better than the competition because, and you better be able to tell me what that is. Give me a list. The closest product to what I have is, you know, for example, I make kanamycin and maybe the closest product is another antibiotic. Well, why is kanamycin better than another product? How am I going to use it? Then what you need is intellectual property protection. And they're basically four kinds and this is the lecture in and of itself, a discussion in and of itself. You can get a patent, a copyright, a trademark or trade secret. A patent is based on novelty, utility, non-obviousness, and then being able to disclose the invention so that somebody skilled in the art can reproduce it. In return for disclosing all of that, you are given a patent which protects your rights for a number of years. Copyrights are for written things. They matter today because if you're going to do an algorithm, you may want a copyright rather than a patent. On the other hand, if you don't have to disclose the content of your algorithm, you may not want that at all. What you may want is a trade secret. You know how it works. Nobody else knows how it works. But you can't do that if you're trying to make a device. If you build a device and patent it, you have to disclose enough for somebody else to reproduce it, otherwise you don't get the protection of a patent for a number of years. A trademark is a sign that goes onto an object and tells you it's a brand. It tells you what it is. So if you look at a car, like say an MG, and you see the letters 'MG', that's a trademarked sign. If you look at Tesla, that's trademarked, but can also be a shape or a color. And in fashion, that turns out to be very important. When you look at the market, is it attainable? Can you actually get to it? So I'll talk personally for just a second. My wife found, worked in Sub-Saharan Africa. She's an ophthalmologist and she discovered a treatment for about 500,000 children with blindness at a very early age. It was a very easy treatment that cost one to 3 cents per child. The problem is nobody can get the medications to the child. So it's a market. It's a small market. I mean, 500,000 times one penny isn't all that much and there's a cost to it, but it wasn't an attainable market. It would've been like trying to bring a new surgical instrument to the former Soviet Union on the Soviet times. You cannot do it even though the need for it is there. And then the market has to be attractive. So the stroke market is attractive, the cardiac market is attractive, the neurosurgical spine market is attractive, the functional neurosurgical market is attractive. You know who's doing it, who the patients are, what the current status is, and how to develop new instruments. Then you need adoption. It turns out some specialties, some devices are more quickly and easily adopted than others. Neurosurgeons are pretty good at early adoptions, you're not the best. Probably the cardiologists are the best. Plastic surgeons are also very, very quick adopters. Other specialties, less so. And so you need to know what the strategy is to move from early adopters to the next stage when it becomes a universal standard to actually use whatever it is that you're trying to innovate. There's certain operational concerns. What I mean by an operational concern is what you need to think about when you run a company. What are the costs? What is the funding? And I'm not going to go through all of this just to respect the time, but dilution. When you get money for a company and somebody buys a part of your company, you're selling your own stake. Are you happy lowering your own personal take or return in order to sell the company? Do you have any choice? One of the things that matters. For both drugs and devices, you need a disease model. So if you're going to have a new drug for multiple sclerosis or you want to try deep brain stimulation for some of the effects of multiple sclerosis, what is your animal model and is it predictive? The FDA will always ask you for mechanisms of action, sometimes more sophisticated, sometimes less. How does it work? Then you need proof of principle, show me that it works. You need to understand the regulatory pathway when you go to the FDA. What are you going to go to the FDA with? What are you going to tell them is primary clinical indication? What are you going to tell them is the primary population, the indication that you're going to give it for? So if for example, you take a screw for an adult spine and you say, I'm going to use this for scoliosis in a 4-year-old child, the FDA will rightly scoff at you because it's not appropriate and you've got to figure out how specific they want to be. Then you need to make the device, that's called prototyping. Now you probably need to make the device before you test it clinically, but you prototype it, then you manufacture it, then you do your clinical trials, then you follow your regulatory pathway, and then you market the product. And eventually, you scale it to the point where it becomes a standard and people aren't buying a one-off, they're actually buying a product which is standardized. You'll also have to think about corporate matters. When people ask about setting up a new company, doing a startup, the question is, okay, you own this, you've got a patent, that's wonderful. What do you want to do? Do you want to do a startup and you have somebody to do it for or do you wanna do it yourself? Or do you want to license this? So many people who work in spine or in vascular or in functional neurosurgery will very quickly try to license their technology to the appropriate companies. Other people will say, I want a startup. I want to grow it to a certain revenue stream and then I'll try to license it because the value will always be greater. You need to think about corporate structure. Are you going to be the only person? Are you thinking of having it go public? Do you want to have a company that perhaps friends and family invest in and that's all? Do you want to run it or do you want a board? That requires either knowledge of corporate law and especially, state law or you need to have really good advisors. And there are people who specialize in helping new entrepreneurs develop a company along the lines of the company needs to be. Not every company needs to be the same. Not every company is going to go public, but it's important to think about what you might eventually want to do and start the company the right way. If you have a company that is going to go public or expand, you may want a board. It's very tempting to put your wife, your husband, your friends, your family on the board, people you think will help you. But that's not always the best idea because on a board, there are fiduciary obligations. And if a company goes south, if it fails, and many companies, many early stage companies do fail, they become personally responsible. So you want to be very careful with the corporate structure and the development of the board so that everybody is protected, everybody has integrity, everybody can bring wisdom and people can help you succeed. And that's the same for the advisors and scientific advisory board. You don't want people around you who will always say yes. You want people around you who are very critical, who've had experience, and can tell you what can go wrong in the company. And then again, I keep on talking about the exit because what investors will want is a company that is small, husband its resources, is very thoughtful about this expenditure of money, but looks like and runs like a large company. And that leads us to the challenges. These are the challenges that often lead to failures. How do you find customers and employers? Where do you have your funds from? What are the laws and policies and regulation? In Cambridge, Massachusetts, for example, you have a real problem if you want to start a company using recombinant technologies. What are the networks and connections that work? People have self-doubt and fear. I'm not a salesman, for example, I never will be, and if you put me in that position, I'll fail. I know that. It's not a doubt, it's a certainty, but I have to know that about myself. How much time do you have? Is there education that you have, information and knowledge that nobody else has? That's a problem because then if you get hit by a bus, the company goes to pieces. You need to be able to disseminate what you do. You need mentors who can provide guidance honestly. You need social support. You have small children and you need to make a decision about whether you're going to be spending time with them on the weekend or whether you're going to be developing your product in your garage or in a company headquarters. Where do you want to build this? At the beginning, it should be near you. Later on, you can be a little far away if that's practical or if a venture capitalist wants you to put the company in Palo Alto or in Boston, so long as you have management to run the company. And then you worry about lack of inclusion based on race, ethnicity, gender, income, or other functions. And people are very concerned about that for good reason. It's only recent that female entrepreneurs have really begun to be successful. And here are the causes of failure. If you don't do the competitive analysis, if you don't understand the market, if you don't understand the financials, if you haven't developed a statement of the product features and differentiation, what makes it different? What the customer needs, what's the traction sandwich? The two points of proof you want that customers need a product and that they are willing to pay for it. One alone is not enough. Then be careful because of technology disruption. Technology is changing a lot these days. For example, there was a certain point when everybody thought every operation in neurosurgery was going to be done either with a laser at one point or minimally invasively or another. Well, not so fast. Minimally invasively, yes, the laser may be less than anybody thought. And there are lots of hospitals you can go to and find very dusty old lasers. So what disrupts what you're doing? Think about research and development, time cost, prototype cost to scale, cost to manufacture operations and company. And by the way, somebody who is a good enterprise leader doesn't necessarily know manufacturing or quality control. You need the people to do that who create the right leadership team and company structure. And the right leader at the beginning of a company isn't the right leader at the end of a company. It's sort of like a residency. What you're excited about doing as a first year resident, it's not what you want to be doing as a chief resident. There's stages of development and you need to match the management and the company. And finally, company acquisition and retention. What does it take to actually find the customers, convince them to buy, and have them come back? People like to talk about a Harvard Business School professor named Michael Porter who said, look, anytime you think of a market, think of five things. Think of where you are and who you're. Think of other people who might come into the market. Think about the suppliers. Maybe the suppliers will start making the product that you've already designed. Think about potential substitutes. So for example, if you have an antibiotic impregnated shunt, one of the substitutes is not having an antibiotic impregnated shunt, maybe you'll just use an ordinary material. And buyer power. Can you withstand the pressure of people who say, I want the lower price, I want different terms, or today more commonly, I buy all my things together from a company that supplies my IVs. You have to sell, not to me, but to the company who sells my IVs because I can't buy anything except from that. Or for example, in pediatric hospitals, there's a buying consortium, and almost all pediatric hospitals buy together through a buying consortium. That's a different purchasing model. There's one more thing to think about, which is the question, is this for you? So there is such a thing as a neurosurgical personality. We're actually pretty special people. We're curious, we're flexible, we're adaptable, persistent, passionate. Most of us are willing to learn for all our lives. We have a broad skillset. Many of us are visionaries, all of us are motivated, all of us are intelligent. However, do you actually have the time to do this? What are the alternatives? Would you rather write papers? Would you rather go the promotion academic route? If you do that, yeah, you'll be able to also have an enterprise, but maybe a little bit later. Maybe entrepreneurship isn't the first thing you ought to be thinking about. And so there's sort of a self-assessment piece that's very helpful. Are you a person who wants to innovate, which means you want to move from idea to product? Or do you want to build a business? There are people I know for whom being the CEO is the most important thing in their life, like being chairman or professor. What do you wanna do when you get up in the morning? Is it patients and surgery? Is it research and publication? Is it innovation and solution? Is it to found the business and to scale it? What are your skillsets? Really, be honest. What are they and what do you want them to be? What are your goals and personal objectives and professional ones? Are you somebody who prefers working alone or are you a team worker? Would you rather play tennis or would you rather play hockey? What is your appetite for risk and failure? Every entrepreneur I know has failed a few times and then gotten up again. There's some places in the world like Germany, where the appetite culturally for risk is very, very small. And so unless you have your own fortitude to overcome that, it's very difficult to overcome that risk. What stage of life are you at? Are you at a stage of life in which every dollar matters and you really have to pay back loans? And so, putting money into a business is a risk that's really not wise. Or do you have a buffer so that you can do that? How much time do you have? What culture are you from? What matters to you in terms of community, in terms of family? What means do you want to follow to have satisfaction? And then what are the sources of fulfillment? At the end of the day, what do you want to turn around and say, I've accomplished in my life? And so let me finish with this one conclusory slide. Being an entrepreneur is great fun. It's really thrilling. It's also a detailed and methodical process, which is no less detailed and no less methodical than doing a difficult operation. It can be learned, it'll speak to your creativity. It can do fantastic good. It can also build wealth. It can also result in tremendous frustration and disappointment. Mentorship, first finding a mentor, and then later becoming a mentor is key. And so is participating in a community preferably of people who appreciate who you are and what you do. So I leave you with a very difficult question of asking, is this for you? If it is for you, if you like it, it's an awful lot of fun and worth pursuing. But if it's not for you, one way of doing some of the same things is to partner with groups in whom there are entrepreneurs or in whom the entrepreneurship skills are available, and accomplishing the same thing in slightly different ways. And if I may, let me stop here.

- I love the lecture, no question. It's really speaking from your heart. And as someone, Teo, who has been so immersed in neurosurgery myself, has done 7,000 complex craniotomies for so many years, for more than 25 years, I can tell you a lesson in entrepreneurship that it is often has times in its journey that are much more difficult than taking out a very large complex AVM. It is not for everyone. You have to learn. And I understand there were some elements you mentioned that neurosurgeons share with, but neurosurgeons don't share with, they're not great people to deal with uncertainty. They're not great people who often can deal with disappointment very well. They're not great people in dealing with lack of being in control. And they often really want to have a very solid plan with a certainty of success. And that's extremely incompatible, in my opinion, with entrepreneurship. Entrepreneurship requires someone who realizes taking risks, calculate risks is reasonable, and you have to deal with those very ups and downs. It's like, you know, valleys and peaks, and valleys of, you know, a very bumpy road. Most neurosurgeons live in a relatively flat road. Just go in the morning to surgery, you have your patients, everybody respects you as a neurosurgeon, and then you can do your work and come home. That's a, I would say, an easy part of life. It's much more difficult when you have to take the risk, not knowing what's ahead of you and you want to make a major change. Those are much, much more challenging in my opinion. What are your thoughts there, Teo?

- I think you're absolutely right, the issue of control and uncertainty. You have to assume sooner or later somebody's going to tell you, you shouldn't be the one to do this, there's somebody who can do it better. You've gotta learn a completely new vocabulary and a completely new way of dealing with people. You've got to understand that not only is it possible you'll fail, you will fail. Maybe not in the entire enterprise, but you know, if you want to laugh at me again, when I was about 12 or 13, I built, I wanted to build a motorized spaghetti fork and I built a little model and it worked beautifully. There were two problems. I didn't figure out how to make it stop in time and the sauce went all over the kitchen, which made my mother very unhappy. What was really interesting when I started studying patents was that the principle of a motorized spaghetti fork that stopped when it was loaded, was taken and patented by Sanyo, and they sell this in Japan as a novelty and people use it, but it's exactly the same principle as a self-stopping drill bit in neurosurgery. It's got load, it's got torque, it's got an engine, and it stops at a certain point. And the difference in the patents are fascinating. They're very, very close. You have to understand that maybe a small word in a patent means that somebody else can copy your patent and you're no longer protected. So you put it absolutely perfectly, Aaron, you have to be aware of what this means, just as if you're operating on a patient, you don't think about what happens if everything goes well, you think about the complications that you need to avoid as you're doing the operation. And it's not for everybody.

- No, I agree with you a 100% there, and I've learned something. Anything that I have learned or have thought it was new, somebody had thought about it already. You just need to look hard enough. There are very, very few things that after doing so many surgeries and Teo you have done, we feel like, "Oh my God, this is so novel. I bet this is so valuable." And then it only takes a few minutes of getting on the internet and figuring it out that somebody had thought about this before many years ago. So your idea was not really what you thought. Teo, thanks for your time, especially coming where you are. It means a lot. Obviously, I have so much respect for you, for what you're doing, what you have done in your life, and tremendous, really tremendous, Teo, to say the least.

- Have a good evening everybody. Thank you very much for your attention.

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