Venture capital meets primary care (or PC2VC)

Show Notes

Daniel is a physician who wears many hats: inventor, founder, investor, and startup advisor. This week he sat down with another physician, Dr. Vineeta Agarwala, who has taken her clinical expertise to a whole other industry. Vineeta is a General Partner at Andreessen Horowitz, where she leads investments for the storied firm’s bio fund (overseeing therapeutics, diagnostics, and digital health).

What is Healthy Conversations?

Healthy Conversations brings together leaders and innovators in health care to talk about the biggest issues facing patients and providers today. Every month, we explore new topics to help uncover the clinical insights and emerging technologies transforming health care in real time.

Speaker 1:
We still have a death by a thousand cuts, whether it's scheduling a mammogram or getting the results out or interpreted. It seems like there's a real gap between the amazing solutions and the ability to implement them.

Speaker 2:
If you have a family member who gets diagnosed with cancer, they're going to need to have care through our existing brick and mortar infrastructure, at least for now. Those institutions, I think, have been left behind a little bit in the digital health flurry. And so, I'm particularly interested in technology solutions that are built within and built to succeed deeply integrated with our hospitals, health systems, and large insurance plans who are really bearing the cost of care for our sickest, most complex patients.

Speaker 1:
The opportunity is amazing, and given that the big payers, from pharmacies like CVS to Aetna to Anthem to the other blues, they're all starting to think about data, digitization, being proactive instead of reactive sick care.
Hi, I'm Dr. Daniel Kraft. Welcome to Healthy Conversations, and today I'm in conversation with Dr. Venita Agarwala. She's a physician, practicing physician, and also a general partner at Andreessen Horowitz. Venita, welcome to Healthy Conversations.

Speaker 2:
Thanks for having me.

Speaker 1:
We're both physicians that are in the mix of technology innovation. I'm sure many of the folks listening who are health care practitioners wonder what it does that a clinician, especially an MD-PhD, like yourself, does all day at a major investment firm like Andreessen Horowitz.

Speaker 2:
We're both deviants, as it were, Daniel. In my own case at Andreessen Horowitz, I get to work with a team of eight folks on our bio investment team to deploy early stage venture capital into places where we think software and engineering and computation can step change both biotech life sciences innovation, as well as digital health and care delivery. We have the opportunity to partner really closely with early stage founders even after the investment, and that, in some ways, is actually my favorite part of the job. And think through what are all the ways in which we could give input on their scientific research strategy, and what are all the ways in which we can help them with connectivity as well across the ecosystem.

Speaker 1:
We're seeing this explosion of innovation partly catalyzed by COVID, both in the biospace, the digital health space. All of them are converging. What mindsets would you encourage folks who are in the trenches as clinicians, or otherwise in health care, that could contribute to this next generation of this new health age?

Speaker 2:
I think the opportunities are just extraordinary at this moment in time. My feathers rustle a Little bit when people say, "Oh, the COVID pandemic is why we suddenly have a digital health industry." Telemedicine is the tip of a very deep iceberg that's been brewing for quite a while in terms of how do you infuse technology into care delivery? And I think it also shook up enterprises a little bit. The speed with which we've seen health care enterprises adopt new technologies has grown. The ways in which you could impact that industry really are myriad for a clinician, and I would really encourage clinicians to think about roles that go beyond what I'd call user research roles where a company is looking to have a physician's lens on the workflow they've set up, or a gut check on whether the results of a particular analysis jive with clinical intuition.
But I also think there's a lot of roles that extend far beyond that. Innovating in this industry requires forging relationships with regulatory bodies, with legislators, with advocacy groups, with patient advocacy groups. There are really substantial roles to be had in that domain. I often think of an internal medicine hospitalist team lead as really a product manager of sorts. They're balancing a whole bunch of priorities. And so, in some ways really abstracting away from your clinical role and just thinking through what are the skill sets I've built in communication and orchestration of care and in team building? What are the ways in which that can influence industry? And I think the answer is many.

Speaker 1:
They don't really teach us product management, or even much in the way of leadership in med school.

Speaker 2:
Nobody teaches product management, even in industry. So, it's a learned job.

Speaker 1:
Speaking of practice, you're still practicing in more traditional settings, and I was curious how you would summarize your experience over the last 12, 18 months.

Speaker 2:
At the beginning of last year, I was working in the oncology department at Stanford and doing a lot of inpatient care, and I currently focus on seeing cancer survivorship patients in a primary care context. I think there were a lot of amazing feats that I think our health care system accomplished. The first observation I just had is, wow. As a provider community, we are committed to our patients, we're willing to take on personal risks that are really commendable, and I hope we continue to keep some of that comradery, even in digital health contexts where I think it's a little bit harder to forge, right? I did have, and continue to have, a frontline view into missed screenings. Yesterday, I met with the patient. Her scheduled annual mammogram, which really is important for her given that she had prior breast cancer at a relatively young age, she had decided not to pursue in the thick of the pandemic.
The order expired. Nobody was aware of when her mammogram was supposed to be rescheduled. It took a weird episodic visit with me, with a provider, to reenter the order and get her screening back on track. It's crazy to me that, despite all the technology we've built around care delivery, we don't have basic notifications set up for that kind of thing. I'm very curious to see this next wave of companies create provider workflow tools that are more oriented around population health, around proactive value-based care nudges that just totally don't exist. And moving to telemedicine isn't going to solve it.

Speaker 1:
Yes, spot on. We still have a death by a thousand cuts, whether it's scheduling a mammogram or getting the results out or interpreted. And speaking of those digital layers, when I was in medical school, and maybe even when you were, there wasn't a course on digital health. Or now, not just telemedicine, but remote patient management, maybe not just bedside manner but webside manner. It seems like there's a real gap between the amazing solutions and the ability to implement them.

Speaker 2:
I love that phrase, by the way, webside manner. I'm going to use that. We learned over the last year that there is a hunger for direct to consumer healthcare that, honestly, I would have to acknowledge that, as a provider, I underestimated. But at the end of the day, I think that's created a divide. Because our sickest patients, if your mom has a heart attack tomorrow, you're going to have to show up at your local health system's emergency department, right? If you have a family member who gets diagnosed with cancer, they're going to need to have care through our existing brick and mortar infrastructure, at least for now. Those institutions, I think, have been left behind a little bit in the digital health flurry. And so, I'm particularly interested in technology solutions that are built within and built to succeed deeply integrated with our hospitals, health systems, and large insurance plans who are really bearing the cost of care for our sickest, most complex patients.

Speaker 1:
The opportunity is amazing, and given that the big payers from pharmacies, like CVS to Aetna to Anthem to the other blues, they're all starting to think about data, digitization, being proactive instead of reactive sick care. The famous phrase that AI's not going to replace your doctor, but your doctor will uses his AI to replace those who don't. What do you think we are on that trajectory?

Speaker 2:
For me, the image that always comes to mind is a very specific memory that all clinicians will have had of doing chart review on a complex inpatient before entering the room. No matter how much information has been thrown at you in some passive way, at some point, you've felt that urge to click through in the EHR every lab value to have digested all the information available to us in order to build our best possible understanding of that patient's current status. And I think about that a lot. There's two sides of that coin, which is that you feel inadequate sometimes analyzing that data. You're like, "Well, if I wish I had time, I'd really look through and see if there were any case reports on whether a cortisol in this range combined with X, Y, Z, other factors is really meaningful, but I don't. And so I'm just going to have to ignore that data point or guess about it."
And then, on the other hand, it's almost like no matter how synthesized that data were provided to you, you don't really feel it in your gut, the confidence to make a clinical call unless you've digested the data yourself. So, to me, those are the two key requirements, actually, of an AI tool that actually works hand in hand with a clinician. One, finding insights that individuals undoubtedly cannot find, which I think is possible and very real. There's no way I could crunch the data of the hospital system's EHR to understand all the other patients who look just like my ICU patient over the last 10 years. And then the second is you have to give me the information in such a way that I feel like I have personally internalized it to get to conviction about a care decision. And so, those are two features that I, unfortunately, don't see in all of the AI driven health care care solutions, and I think in both those features don't cut the clinician out of the loop at all.

Speaker 1:
What's your perception of social media platforms, like Clubhouse, for, especially, clinicians and even researchers, folks talking about vaccine hesitancy all the way to drug repurposing?

Speaker 2:
I think it's just really phenomenal to see all the modalities for groups to come together, learn quickly, crowdsource suggestions, share clinical vignettes. I do think you're only seeing, sometimes, one side of the story or you're, there's just all kinds of bias that we're not aware of based on who's there and who's not. It's important in group settings to make sure that there are folks specifically to hear or view that would otherwise be missed.

Speaker 1:
I'm curious, in your practice, have you seen any vaccine hesitancy? How do you communicate the complex lessons in the setting of vaccines to your patients?

Speaker 2:
Not just patients, but acquaintances or second, third degree folks who I've just had social interactions, conversations with. So far, in all the patients that I've seen, for example, even post bone marrow transplant even who do have graft versus host disease, none have had complications. I think more literature will be published soon on this, but I think we've realized it's safe. The most helpful data for a patient is to tell them about other patients who look a little bit like them who've made it out on the other side well, and that could mean people from their community, that could mean patients with similar comorbidities, that could mean other patients that are seen at the same practice and have a sense of community indirectly through a provider.

Speaker 1:
You're at Andreessen Horowitz. You've got also incredible media at a16z. You see a lot of things early, and mix it up with the best and brightest in health and health tech innovation. Anything that's surprised you you learned lately about things that might be underreported?

Speaker 2:
One of the biggest surprises, again, on the global scene, to me, has been just how little visibility we had into waves of extraordinary pandemic in other countries, like India, Brazil, all over the world. I don't think we've nailed why. Why that happened? Why that happened so suddenly? We might be underestimating the role of future surges in Africa and other parts of the world where they just haven't even happened yet. I think still how little awareness we fully have of the global interconnectedness of our population.

Speaker 1:
Yeah. We all live on one spaceship earth, and one of the lessons, yes, is how quickly an epidemic can spread to a pandemic. So, obviously, one of the pioneers across vaccines is has been Moderna. Actually, I was a postdoc with Derrick Rossi in the Weissman Lab at Stanford, who-

Speaker 2:
Oh wow.

Speaker 1:
... originally founded Moderna. It stands for modified RNA. Most people don't realize modified, Moderna.

Speaker 2:
It is absolutely remarkable that that story played out the way it did. The public private partnership was really effective in scaling up clinical development and manufacturing efforts at a rate that we've just never seen before in the biotech industry.

Speaker 1:
Can you maybe share what are some of your perceptions and possibilities of where mRNA as a platform could go in the next decade?

Speaker 2:
I really think the possibilities are endless. Effectively, you're delivering a copy of a gene. You could use that gene to encode a protein that you're delivering in a replacement context. You could use it to deliver a new moiety that wasn't missing, but could be helpful in the same way that you deliver any other sequence encoded therapeutic. What if you could deliver an mRNA encoded antibody? Could that be a more effective way, and if you could have more control over where you guide that RNA to get expressed in the cell.
That could unlock something special even outside of a gene replacement context. Could you deliver something that modulates the immune system in some way in a very specific targeted site of disease? In the oncology context, people have been thinking about the concept of cancer vaccines for some time. Could you prime the immune system to generate recognition of certain cancer antigens? The short summary there is that, yes, it seems like you can, but it's not quite as easy as we thought either. I think we're going to see that play out over the next several years in terms of what those applications are for RNA.

Speaker 1:
Let's zoom back again. Maybe help folks understand your personal journey. How did you end up where you are? What kind of personal experiences brought you into Venture Capital and to Andreessen Horowitz?

Speaker 2:
My own journey, I think, was mainly driven by jumping into opportunities that I thought were exciting that were right in front of me. I have to say, most of it was not particularly scripted or planned, and that's the whole point of startups, right? The main thesis that I followed is, "Hey, if somebody great is working on a problem that I think is really important, and there's some way in which I could contribute," I really tried to figure out a way to join that team, and that was a recurring theme for me. I had a chance to work with some really great founders at companies in the Boston area.
That's actually where I first met Julie Yu, one of my partners now here at Andreessen Horowitz. Even though those non-linear steps can be painful and can feel sometimes like you're jumping off the train, so to speak, you can always jump back onto the train. Actually, I first joined McKinsey before I went to medical school and just pursued things that seemed non-linear at the time right there in front of me and felt like that they'd be really fun, candidly, and/or have a certain type of impact. So, that's been the predominant thread.

Speaker 1:
In my own path, it was always about following the bliss a little bit. But seeing all these conversion ideas, seeing pain points across healthcare, trying to figure out if I could solve them or not. Speaking to that point, where do you see in the health care marketplace, particularly high demand for clinical expertise. What are companies looking for? What do they need physicians for? And how might clinicians of all sorts reach out to start a conversation?

Speaker 2:
Yeah, I'll try to give practical advice here, which is look for roles that directly use your clinical background, but also be open-minded to roles that seem like they're not linearly tied to your specific clinical backgrounds. That could be roles in regulatory affairs, all roles where maybe you haven't had specific experience, but your core skillset as a hardworking, energetic competent person can be useful. The key is to just meet with as many companies and people as you can when you're first navigating into industry, just because you get a lay of the land that way, you get a sense of different roles that are available, and you need to hear about all of them to make that decision. I think reaching out to founders directly. We talked about social media before, but sometimes that can be a great recruiting tool, as well.

Speaker 1:
So, sometimes you don't need to make the exact completely to industry. Many folks act as consultants. Many academics found companies. Good to keep your medical license. Any downsides you've seen for clinicians moving into industry?

Speaker 2:
The major downside that I see is underestimating how attached and how important the clinical service mission really is to you. And sometimes, that can manifest as just directly missing the opportunity to do patient care.

Speaker 1:
For me, it's been the patient care component where you get the inspiration, you see the ideas, the dots connect, and then the magic can start to happen. Maybe just for, in our last bit, we can nerd out a bit. I'm a bone marrow transplanter by background. You're dealing with patients with GVHD that survive transplants. What are some of the ways you think we could reinvent the whole, not just, well, the cancer patient journey, but also post-cancer journeys?

Speaker 2:
Yeah. Kluge is right. I think there are so many opportunities to change how the cancer patient's journey goes. One is around helping patients be cared for close to home. I think there are a lot of opportunities to bring access to genomic testing, to hereditary risk stratification, to bring access to clinical trials much, much closer to the patient's home. We've forced them to come in just for a screening visit, and I have seen patients, obviously, as I'm sure you have, who travel six hours to be screened for a clinical trial. We could just do a lot better to help triage scary situations for cancer patients. Unfortunately, cancer patients run into a lot of scary situations.
We prescribe an oral chemotherapy, send them home, and we know that on a particular day after prescribing that they're supposed to expect a rash on their hands. But the only way we educated them was we sent them home with a printout that described a set laundry list of side effects of that therapy. And so on that day, they present to an urgent care center or an emergency department saying, "Oh my gosh, what's happening to my hand?" There's just so much opportunity for education and transition for patients back into primary care and helping patients get back onto a path of more global wellness. That, for me, is really personally satisfying.

Speaker 1:
Yeah, a hundred percent. We all have the opportunity not to just predict the future, but to boldly create it together collaboratively. So, thanks so much for joining us in Healthy Conversations. Congratulations on all the amazing work you're doing at Andreessen Horowitz and beyond, and Godspeed in helping continue to catalyze the future of health care.

Speaker 2:
To you, as well. Thanks for having me.