Reflections on ‘why’

What the fuck am I doing?

There hasn’t been a day in recent memory where this thought hasn’t crossed my mind. A few years ago, I stepped back from tenured academic job to start a healthcare company. Last year, I gave up whatever remaining stability I had when I moved to LA. Sounds glamourous. It isn’t. For most of the last 9 months I’ve been living here alone. 5,000 miles from my home, from my wife, my dog, my friends, and everything familiar. When I’m here, all I do is work. Most days start at 5am so that I can be on the same time schedule as my team back in Ireland and I keep going for as long as my mind allows. Then rince and repeat.

To most people, these kinds of life decisions make no sense . But for people that found start-ups, it’s not that unusual. Most of the few friends I do have in LA are founders and live a very similar existence. What’s strange to me is how seldom we as founders ever talk about ‘why’ we make these decisons and put ourselves in these kinds of situations. Instead we focus on the ‘what’ - what product we’re building, what opportunities we’re pursuing, what investors we’re pitching, what hires we’re going to make… Most people that know me, know the ‘whats’. I’m writing this essay to (try to) explain the why.

Healthcare is Broken

We all want to live long and happy lives, free from unnecessary suffering, pain and illness. To do this, we need a functioning healthcare system. Unfortunately, we don’t have one and all signs indicated that the situation is going to get much, much worse.

Let’s start with hospital capacity. In the 70’s and 80’s, in countries like the US and the UK, there were 8/9 hospital beds for every 1,000 citizens; now there’s 3.

At the same time, our populations are aging. Older patients use more hospital services, stay longer, and require more complex care. Meanwhile, the healthcare workforce is shrinking. Not only that, but fewer people want to work in healthcare. The WHO predicts a shortage of 4.5 million nurses globally by 2030. In the past, societal expectations and limited employment opportunities forced a large number of women into nursing. This isn’t the case anymore, although women still represent nearly 70% of the health and social workforce.

There isn’t just a recruitment problem - there’s also a retention problem. Approximately 50% of newely hired nurses quit before the end of their first two years of service. Why would they stay? Conditions are brutal. Shifts are long. Burnout is endemic. Pay isn’t great.

Why don’t hospitals pay staff more? Because they are broke. In the US, approximately 40% of hospitals are losing money. In most countries, healthcare spending represents more than 10% of GDP (in the US, its nearly double this).

So in summary; we don’t have enough physical hospital beds - demand for healthcare services is steadily increasing - we have a chronic staffing shortage that’s getting worse - and relatively speaking, there’s very little money available to solve the problem.

Fixing the Wrong Problem

When policymakers talk about fixing healthcare, they often talk about building new hospitals. This is a mistake. First, it takes a decade or more to plan, fund, and construct a hospital. Second, by the time it’s built, the assumptions it was based on are often obsolete. More importantly, focusing on infrastructure distracts from the deeper problem: we’re terrible at running hospitals efficiently.

Hospitals are chaotic systems. The cost of running a single operating room frequently exceeds $50 per minute, and yet hours are lost every day to preventable inefficiencies: delays in patient transport, misaligned schedules, equipment that isn’t ready, rooms not cleaned in time. These aren’t edge cases - they’re systemic.

Ironically, some of the most expensive environments in healthcare are also the least optimized. Hospitals spend billions on infrastructure, but very little on improving how that infrastructure is used. There are startups trying to tackle this, but most of them address narrow problems. Point solutions don’t scale well in healthcare. The integration cost is too high.

What’s needed is a system - a platform that works like an electronic health record, but for hospital operations. A single, unified layer that makes the invisible visible, the manual automated, and the chaotic coherent.

A startup will win

There are only a few ways this kind of change could happen.

The first is that hospitals themselves figure it out internally. They reorganize, invest heavily in development of in-house solutions, and then build the infrastructure internally. This is very unlikely. In the early days of electronic health systems, several health systems tried this approach and it turned out to be a complete disaster.

The second is that incumbents like EHR providers or medical device manufacturers expand into operations. This is also very unlikely. They’re already complex and vertically integrated. Adding another layer would require them to build entirely new businesses divisions which don’t build on any of their core competencies. It would be like Google deciding to sell computer monitors.

The third possibility is that an existing provider from outside healthcare enters and disrupts it. That works in some verticals. But healthcare is notoriously hard to break into. You need to understand not just the workflow, but the politics, the incentives, the culture. Without that, even the best technology won’t be adopted.

That leaves startups.

Not just any startup, but a very specific kind: one with a real technological edge, a deep understanding of hospital operations, a willingness to build for the long term, a deep connection with the problem, and a team that can retain optimism and conviction in their vision to bring about meaningful change no matter how bad and disinfunctional healthcare may seem.

“If not you, who”

That’s what an old rugby coach used to ask us before big competitions. It stuck with me.

If you're like me, you can come up with a dozen reasons why you might not succeed. But it's harder to find a reason why someone else will; what are others doing that puts them in an objectively better position that what you’re doing.

When I imagine the startup that could actually solve this, I don’t see a perfect team with a flawless plan. I see a small group of people who are obsessed. Who know healthcare because they’ve worked in it, lived it, endured it. Who know this won’t be fast, easy, or glamorous and are fine with that.

I see a team that cares. That care about the staff that need help. They care about the patients because they know, sooner or later, it will be them or someone they love in that position. They care about the details; about clean code and good design. They care about building systems that work and last. They care enough to suffer through the thousand pivots it takes to make a dent in something this hard.

I see a team with zero ego that’s willing to do what it takes. That realizes that while they may not be the most experienced or the most resourced, they might be the most resilient and over time this compounds. And when it comes to solving hard problems, that’s often enough.

I see us.