Dr. Bruce McCormack is a board-certified neurosurgeon who lives and practices in San Francisco. He is also a prolific inventor and highly successful entrepreneur. In this episode, Bruce gives insights on his decision-making throughout his career and the power of seeking opportunity in change. Jeff and Bruce discuss the importance of knowing Why people pursue specific goals, especially when tackling healthcare’s biggest problems.
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Start With Why With Neurosurgeon & Startup Founder, Bruce McCormack, M.D.
Welcome to episode one of Unmet Need. This is a special episode, not just because it’s the first, but we’re joined by a dear friend of mine, a mentor, and somebody I respect very much, Dr. Bruce McCormack. Dr. McCormack is a Neurosurgeon in San Francisco and is the Founder and Director of the Neurospine Institute. He started his education at Brown University and attended medical school at Columbia University College of Physicians and Surgery.
Dr. McCormack went on to do his internship at Mount Sinai Hospital in General Surgery and then went to NYU Medical Center for his Neurological Surgery residency. Following that, Dr. McCormack did fellowships at the University of Florida and the University of New Mexico. Dr. McCormack was the Director of the UCSF Neurospinal Surgery Service and Assistant Professor of Neurosurgery.
As you can see, Dr. McCormack is a successful person, but it’s not so much about success and accomplishments that I want to talk about in this episode because the purpose of this episode is to bring some light and attention to how significant every individual why, the starting with why. Unmet Need is a show where we talk about solving or attempting to solve the biggest problems in healthcare and our audiences are primarily entrepreneurs, executives, investors, and builders.
As builders, it’s one of the things we all talk about. In this episode, Dr. McCormack will share some of his experiences throughout his career, what motivated him to strive constantly, and what different things he considered when he made the deliberate choice to continue to study, sacrifice, and help so many patients. I’m happy to have Dr. McCormack on the show. Bruce, we’ve known each other for a long time. If it’s okay, I’ll use your first name.
Thank you. It’s a pleasure to be here.
For me, starting a show is yet another startup, and in many ways, for us. For the audience, Bruce and I have done several startups together. One is Providence Medical Technology, which is a spinal implant business focused on establishing circumferential cervical fusion as the standard of care for high-risk patients.
We’ve been at this together for many years. Companies made a lot of progress. We’ve helped over 10,000 patients. We’re involved in a randomized controlled trial to demonstrate superiority and help realize this mission of becoming the standard of care. This episode is not going to be a discussion about Providence specifically. Throughout the course of these episodes, I’ll share some of the things that I’ve learned, insights and mistakes. Since we have Bruce on, I want to start with why did you become a doctor? How did you know that this is what you wanted to do?
My dad was a dentist. I was always good at science and interested in it. When I was at Brown University, I gravitated toward Life Sciences. I thought of going into Medicine. Initially, Dentistry would be a good start. I wasn’t sure where it would lead me, but I felt a medical degree would give me a wide platform in order to do other things.
At what point in your medical training did you gravitate towards General Surgery and eventually Neurosurgery?
I was always interested in the brain. To me, it seemed that the greatest organ. The kidney is great, but the end product is urine. The brain, the end product is thought. When I was at Columbia Physicians and Surgeons, I did research on myasthenia. I ran the neurosurgery lab for Bob Solomon, who was the chief resident in Neurosurgery. I was interested in the brain, and specifically neurosciences. I tried Psychiatry. I found it depressing. Neurosurgery seemed a great field for me because it was a more tangible approach or hands-on approach to the brain. As a former athlete, that appealed to me, the physicality of it.
Two things I want to unpack there, they’re interesting. First, what did you find depressing about Psychiatry?
The brain is the greatest organ. The kidney is great, but the end product is urine. With the brain, the end product is thought. Click To TweetI don’t know. I tried it. I was always interested in Freud. I had read his books. Ultimately, the practice of it didn’t appeal to me. Sitting there for an hour, talking to someone or listening to them. I was interested in Psychiatry in theory, but the practice of it, I didn’t find compelling.
You mentioned that neurosurgery is tactile and you can have a direct impact and see what you’re trying to accomplish, versus what I imagined psychotherapy is like when you can’t see or touch anything.
That’s probably better stated than the way I was trying to state my dispassion with it.
The other thing, and I know because we’ve talked about it at length, but you mentioned that you were a college athlete. What sport did you participate in?
I was a competitive swimmer, which fit my personality. I was dogged, a good student, and did not shy away from work. Competitive swimming is a lot like that. It’s a lot of repetitive training, which appeals to my nature.
Would you say your ability to be, as you say, dogged and put in the work, does that make you a good fit for Medicine, or is that not necessary?
It helps. You want a smart doctor, but more importantly, you want a doctor who follows up on everything and dots the I’s and crosses the T’s. In Neurosurgery, in particular, you need someone who has the capacity to focus for 3 to 4 hours without any loss of attention. Swimming 10,000 meters in a day focuses one’s attention, or it requires someone to be focused to do that. In that sense, neurosurgery was a good fit for me because I have the capacity to focus.
When we met, and for the audience, I was trying to break into the medical device business. I worked at a company called Cardinal Health and was recruited to a growing business based in Sunnyvale, California, in the Bay Area called Kyphon. I had the good fortune of being assigned Dr. McCormack as my customer. Dr. McCormack was already one of the leading surgeons performing this particular surgery called kyphoplasty.
It was a hard thing to break into because he didn’t have a lot of use for me, in part because the previous representatives had done a great job and he’d done many cases. I learned firsthand how focused you are and trying to get in that focus with the hope of adding some value so that I could get to know what you needed within the case, or some way that I could help as a sales representative.
That was a problem in a good sense. It was a challenge. If I think about the entrepreneurial journey, what we’re always doing is tackling a problem. It’s my belief. When people say entrepreneurs are born or you’re a natural entrepreneur and natural this, I don’t know if I believe that necessarily. However, I do think there are people out there in the world, many of them, that when they see a problem, they can’t stop thinking about it.
The challenge of trying to address it, it’s exciting until it makes them a little nervous, but it’s one of these things that motivates you and drives you to tackle that problem and somehow solve it. If you think about the problems that you saw in neurosurgery, if we fast forward, for the audience and someone who is not familiar with medicine, how many years of education and training until you were a neurospine surgeon?
It’s the four years of medical school at Columbia. There was one year of General Surgery. There were six years at NYU Neurosurgery department and then one year of additional fellowship training in spine surgery. I was about 32 or 33 by the time I was a practicing neurosurgeon.
You take those twelve years. There were four years at Brown, building out your interest in Life Science. That’s a long journey. One of the things that I went into the entrepreneurial experience ignorant of is how long things take. If I think about the commitment and the dedication you exhibited to stick it out, you knew going into it that it was going to take a long time. It wasn’t like a path where you can do it in six.
I’ve seen it in myself. As a father of four boys, I’ve seen it in my kids. I also see it. People earlier in their career, there’s this drive and interest to be an expert or to a fault leader and speak at events and tell people how they should save money, how they should be a salesperson, how to be a great leader. My belief that I hold pretty strongly is you can’t start teaching until you get out there and learn. I have a lot of admiration for neurosurgery. All physicians and specialists that keep going. At 32 years old, there’s a lot of delayed gratification where maybe your peers and friends are 5 to 6 years into their careers.
They’re making some money. They’re getting married. They’re having children. There was a lesson in that for me, certainly. It’s one of the things I’ve modeled in working together and learning from you for all these years is that one, half of life has shown up, and two, you got to put your head down and do the work. That’s an important lesson for all of us to remember.
It wasn’t drudgery the whole way. I was a natural student and I enjoyed it. It never seemed drudgery. You have to enjoy the path to the now, if you will.
That brings me to a quick topic and then we’ll come back. My why, being completely honest, at 29 years old for being an entrepreneur, it was an event. It was some milestone, an IPO or an acquisition where it was a binary outcome. When that outcome was achieved, I could enjoy it. It’s not even so much about money because I don’t have a lot of stuff that I like to buy, but it was like scoring a goal or getting an A or a pat on the back. It’s gratifying.
What you said eloquently, which I identify with, is it’s not drudgery if you like the work and you are in the moment, say what I’m doing. Number one, it matters. It’s consistent with my values, my purpose as a human being and contributing member of society. I’m going to do it one day. I’m going to do it tomorrow, but you do it one day at a time and you can accomplish important things that you can’t do overnight. That’s an important point, though, is that the journey has to be why you’re doing it. It’s at least part of it. You’ve finished your training. How did you end up living in San Francisco?
Charlie Wilson, who was perhaps the most famous neurosurgeon in the United States, offered me a job at UCSF. By that time, I had established some credentials in spine surgery. I wanted to be part of an academic center. I wanted to be involved in change and beyond the leading edge, if you will, of my craft. I moved out to California. I joined the faculty. I got a research grant on spinal cord injury studying NMDA receptors at the VA. That was back in 1994.
That must’ve felt great for Dr. Wilson to recruit you. For the audience, why did Dr. Wilson become so famous? What was he known for?
He was probably one of the most prolific neurosurgeons in the United States. He pioneered the transsphenoidal approach for pituitaries. He ran an academic department. Probably for 25 years, the primary admitting diagnosis at UCSF medical center with a brain tumor. He was that good. He created a vast body of literature and started the Brain Tumor Research Group. He was a powerful man who created a wealth of research and opportunity at the university. UCSF was the number one training program in neurosurgery in the world.
In my experience trying to break into the spine space in the Bay Area, all the surgeons that Dr. Wilson recruited or trained or inspired are all over the Bay Area and the country. It’s interesting. Dr. Brian Andrews published a book he wrote about Dr. Wilson and his impact on him throughout his career. That’s another thing that in this process of the journey of trying to solve a problem. While you can be focused on achieving a certain goal or tackling a problem along that path, whether it’s intentional or unintentional, we touch a lot of people. You create opportunities for others to learn that is at a different stage of their career. I’ve heard so many great stories about Dr. Wilson and the impact he made on patients and the surgeons following in his footsteps. It’s inspiring.
Surgery is all about knowing where you are and knowing the anatomy. A navigation system prevents a surgeon from getting lost. Click To TweetI want to come back to that real quick, though, because here’s this legendary neurosurgeon, I believe, on the cover of Time Magazine one year or some national publications, but yet when you decided to do your fellowships. I know you’ve been trained for brain tumors and you do a lot of cranial-based work, but what was it about spine surgery? You could have done anything.
Paul Cooper at NYU suggested going into spine because there was a lot of change. There were a lot of new things and developments. He felt where there was a change. There was an opportunity. I remember he told me that. At the time, I was going to do a brain tumor fellowship at Johns Hopkins with Harry Brehm. They accepted me. I was ready to go. Paul Cooper said, “I wouldn’t do that.” He outlined X, Y, and Z, why spine would be a better choice. There were many new technologies being brought to bear in the spine that hadn’t been present before. For a young, ambitious guy like myself, I would be afforded more opportunities in it.
From a pattern recognition standpoint, those details are specific to that time to surgery. When I think about spine and why there was so much change and opportunity, there were all these new technologies that were being developed and implemented. That’s a pattern, as entrepreneurs, we all look for. A minimally invasive spine enabled by fluoroscopic guidance was a catalyst for a lot of innovation. If we fast forward twenty years, many other enabling technologies have pushed the field even further and enable surgeons to either achieve better outcomes, be more efficient, or have a smaller footprint on the patient. That wave of enabling technologies and looking for the wave because it tends to build. A great example would be what’s happening with robotic navigation. Navigated surgery has been out for how long? When was the first time you used navigation?
1995? We’ve used navigation. It was primitive, fluorescence, since the early ‘90s, but in about ‘94, ‘95 Medtronic first came out with an intraoperative navigation system in the operating room. It was a little clumsy. Particularly for spine, we didn’t use that much, but that was my first experience.
For anyone that’s not familiar with navigation, what’s the value proposition? Why is it worth pursuing?
Surgery is all about knowing where you are and knowing the anatomy. A navigation system is a way to prevent a surgeon from getting lost and mishaps happening. It makes the surgery safer, smaller footprint on the patient in terms of getting the surgeon where he wants to be if he knows where he is all the time. It’s safer, better.
What I love about it as a case study on what would I like to think of is that it was Mike Maples published something about technology ways that when they start in the gathering phase, there’s so much promise because conceptually, it makes a ton of sense. Why wouldn’t you want to know exactly where you are at all times? It takes somebody to say, “This is a problem we can’t solve.” Many iterations of navigation systems. They were expensive initially. They’re limited by certain technologies that are required to make them happen.
As that technology wave in the gathering stage, it starts to build. A lot of times, there’s this thing that’s described as the peak, we’ll call it peak enthusiasm, but I think I’m messing that up. That’s where all the capital entrepreneurs and people that think there’s an opportunity to be successful because the wave is gathered and crusted.
It’s usually then followed by the trough of disillusionment. All the investors lost their money or the entrepreneurs, it took way too long. The space thins out a bit. There’s this next exciting point where people start building useful applications on top of that technology. It tends to coincide with when the underlying tech of the solution matures and gets there.
Navigation, I love it because it’s a double wave. That was a long time coming. Only because of navigation could. I would say robotic surgery is now in the gathering stage because most of what surgeons can do with robotic navigation is limited. It’s not robots doing the surgery. There are certainly amazing examples with the da Vinci, the Mako, and the Renaissance, but then there are some amazing technologies. If you fast forward and we’re having this conversation a decade from now, you can imagine there will be many more useful applications for robotic navigation.
Going back to this theme, 4 years of undergrad followed by 12 years of training, it takes time. The people who are having success with robotics didn’t just get into it. It’s a long time coming. That’s a recurring theme. Bringing it back to the topic of this episode, if you’re going to spend fifteen years of your life trying to take this idea of robotic navigation or even navigate practical navigated surgery, you have to be ready for the long haul.
That’s going to require a strong why. “Why am I doing this? Why am I going to spend a chunk of my career pushing this boulder uphill? If I think of some of my failures in entrepreneurial projects that I started, why wasn’t that sound? I had an idea for a problem and I wanted to make something, but I didn’t have the amount of conviction it takes to take it the distance and solve the problem.”
Sometimes they start out trying to solve one problem. They ended up solving another.
It sounds a little bit like our experience. That’s part of the beauty of it. When you were on your journey and so you get to UCSF, you’ve done your spine training, and now you’re at this prestigious academic university, what did it feel like? Did you realize that, “This is it? This is where I’m going to be?”
No, I was a little disillusioned in the sense that I had always thought that this would be the pinnacle and that would be it, and then I would be satisfied. I saw innovation that wasn’t coming out of the university. Most of the innovation is foreign and comes from the private sector. Great ideas. Doctors not associated with large prestigious universities have great ideas and a huge impact. I started to second guess myself and question why I was here.
My interest in spinal surgery was mechanical and physical, which appealed to me as an athlete. My research project on spinal cord injury wasn’t getting me that excited. I felt like there were better venues in order to make changes in medicine. I decided to leave. I thought perhaps a little hubris called a Neurospine Institute because I was still dedicated to the proposition that I wanted to be an agent for change, make something new, or be a pathfinder.
When you told your colleagues at UCSF that you were going to leave the university and do your first startup effectively, the Neurospine Institute, you started it from nothing and hung a shingle and compete with this massive institution, what did people say?
They said, “You would fail. You’re not going to make it. There are few surgeons left.” One of the residents said to me, “Go ahead and try. If you fail, so what?” I was like, “Yeah. Okay.” I went ahead and did it. I always tell people when they’re starting something new, there’ll be a ton of people telling you it won’t work or it’ll fail, but you believe in yourself. There’s room at the top and judges go for it.
Another point is the importance of having friends and family that can give you a little bit of a nudge of encouragement. It’s invaluable. You get started at Neurospine Institute. When did you know that you have a shot, that maybe you can build a successful practice?
I was all hands on deck the first year. I was 100% focused. I would run out to the community and give lectures all over Northern California. I would go up to Eureka, Fresno, Modesto. I would give talks and meet primary care physicians. A lot of people weren’t willing to do that, to build a practice. It snowballed from there. Within a few years, I had an extremely busy practice, almost to the point where I was too much.
It’s interesting because there’s a business model angle to that in that the way I understand it, as you described it in the past, is this idea of getting out into the community as a neurosurgeon and saying, “I’m here. This is the value I can deliver. I’d like a chance to earn your trust as a referring physician.” That wasn’t done as often. To go out and do that in a competitive market and even go places outside of the city, whether Sonoma County or further, one of the lessons I take away from that is incumbents in any industry or marketplace, they’re doing it a certain way.
If you’re the new market entrance and you have likely less resources, less momentum, to try to compete with an incumbent the exact same way, that’s playing a game that they’re well suited for, and there have more resources to play. You chose a different business model. In doing that, I could compete.
As a neurosurgeon, adopting new technology is a way to differentiate yourself from the competition. Click To TweetI had the ability to make lectures and give talks because I was familiar with that as an educator and used that not to educate but more to market my practice and my skills. It was successful.
To fast forward, Neurospine Institute was and still is a thriving practice, still incredibly busy. When we met, I happened to have the good fortune of working for a great company and having one of these game-changing technologies. You were an early adopter. Do you think evaluating new technologies as a surgeon, does it help you build your practice? Does it help expand your reach when you’re at the forefront of new technology?
Yes. Adopting new technologies was a way to differentiate myself from the local neurosurgeons in the area. When I saw that they could provide better patient outcomes, I was quick to jump on board, or if the new technology was solving a problem, for example, kyphoplasty, we had nothing to offer these patients who had compression fractures except pain medications. Here came along an idea to surgically fix these, which made sense to me immediately. I jumped in.
It goes to the inspiration for this show, Unmet Need. It was hard to deny the unmet need for a person with osteoporotic compression fractures that get worse if they lay in bed and to prescribe bed rest and pain medication that was the best available. As an entrepreneur, when you see a large population with clear clinical problems, it’s not difficult to diagnose. That was one of the other things. You can point to it and say that patient has a compression fracture.
All this pain, you can see them wincing in pain. Their loved ones are telling you they can’t do what they used to do. That’s an unmet need. It’s clear unmet clinical needs. Having a technology that can address it is one of the reasons, so many patients have had so much benefit. As the entrepreneurs, Dr. Mark Riley and Dr. Karen Talmadge, for them to have the foresight. That was a long journey.
I had a chance to hear Karen Talmadge speak a number of times. She talks about how hard it was to raise any capital. One of the checks and balances we have within healthcare is the institution, whether it be a particular society or the publications and peer-review journals. They often represent the conservative approach to treating a patient because so much of medicine, as I understand, it’s based on precedent, what others have done.
In doing so, you get a standard of care, which is important. That’s one end of the scale. On the other end of the scale are entrepreneurs that see this unmet need. They have the enthusiasm, maybe the hubris. Maybe they can’t stop thinking about the problem to go out and tackle it. I know in our experience, when you’re coming up with something that’s differentiated and challenges, the status quo, met with a lot of resistance because if you a part of the status quo, particularly if you’re influential within the institution or the incumbent group, you have a motivation to keep it that way.
These disruptors come out with arguably a new or better way of treating a patient. That’s unsettling for some people. Unmet need, as healthcare entrepreneurs, we’re talking about an exciting patient-care device, kyphoplasty, but an unmet need could be an unmet financial need. It could be health care services. How do we deliver healthcare? Some of the interesting Telemedicine concepts. It could be more on the plumbing infrastructure side. The person I was talking to before this interview about the challenge of covering cases where sales reps are in surgery.
As technical experts of the products they sell, but in response to something like COVID-19, does the world change when we come out of the shelter in place, social distancing environment? Our sales reps, are they going to be able to have the same access to the operating room? There will likely be an unmet need.
Products that are already in the works, some exciting technologies that are going to address that unmet need, but I do think, which is why I chose it for the title of this show, there has to be an unmet need because it’s a fancy way of saying a problem. Once you quantify how big the problem is, that’s one of the first steps. One of the lessons that I’ve learned and have observed in other more successful entrepreneurs than me is if you’re addressing a big problem, a high degree of unmet need, the next thing is, what is the solution?
What is the underlying technology of your solution? If that is something like machine learning, gene sequencing or it revolves on quantum computing, you’re building a solution and the foundation of your solution is growing exponentially in its capabilities. That’s where some of the most important innovations come from. A great example, going back to earlier in the call, is navigation, the components that enable navigation, robotics. They keep getting more and more powerful and less expensive over time.
Exponential technologies as the core of your solution give the entrepreneur a big advantage because if your entire solution is built around Polaroid film on a long journey, you might become obsolete along the way. Also, last part of the interview, I told you we would keep it relatively brief, but I appreciate the time. I’m having a lot of fun. You have this successful practice. You accomplished all these things throughout your career. How did you decide you wanted to start inventing medical devices and founding companies?
Number one, as a doctor, I’m relatively risk-averse for the reasons you stated. Our training is dominated by what’s been done in the past, what is safe. Doctors in and of themselves are hue or inherently entrepreneurial. Our training is against that. It’s meeting the right person and having a willingness to take risks. In terms of meeting the right person, I met you, someone in the industry with a much lower risk threshold and has some business wherewithal.
It was a good combination because I understood the problems in spine surgery, and in particular, cervical spine surgery, but didn’t have the business wherewithal to get things going. Understanding your weaknesses and partnering with someone who provides alternative strengths was a strategy of success for myself.
Lucky for me. In wrapping up, first of all, Bruce, I enjoyed the conversation. I appreciate you experimenting on this platform for the first time. I want to try something that hopefully will be fun for the readers. We’re going to call it, Going to the Vault. We’ll end every episode with Going to the Vault. The idea with the vault is I want to ask you three questions. Whatever the first thing that comes to mind is. It’s just three. The first one is, what is something that you read throughout the course of your life that had a profound impact on you that you still think about now?
Nietzsche, Thus Spoke Zarathustra.
Who in your life has been the most influential teacher, coach, or mentor?
My father.
Why?
Unconditional love.
The final thing, from your elevated position in healthcare, what is one problem that you’re confronted with daily or weekly that you can’t stop thinking about?
One of the challenges of aging is pain. A lot of the pain that I focus on is nerve root pain, spinal cord injury pain, or the wearing out of the spine. I feel there’s got to be better solutions for that than doping people up on narcotics, and better solutions and maybe fusing their disks. There have to be better solutions out there.
You read it here, folks. Nietzsche, his father, and we got to figure out pain. Bruce, I appreciated the time. This is the end of the first episode. Thanks very much.
Thank you for having me.
Important Links
- Neurospine Institute
- Providence Medical Technology
- Mike Maples, Jr. – How to build a breakthrough
- Thus Spoke Zarathustra
- Start with Why
- Gartner Hype Cycle