Open or Closed Robotic Systems – Are We at a Crossroads? Featuring Stuart Simpson - Mastering Medical Device

Episode Transcript
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Patrick Kothe (00:31):
Welcome.
Surgical robotics continues toimprove and evolve.
However, there's one issuethat's getting more and more
attention.
Most of the surgical roboticsystems are closed, which means
they'll only work with onerobotic company's products.

(00:51):
This was appropriate in theearly days of robotics to assure
proper function of the system.
But as robotics use continues tobe embraced, hospitals face a
dilemma when they use differentsurgical products that only work
with one robotic system.

(01:13):
Will they need multiple robotsin their ORs to enable their
surgeons to use differentmanufacturers products?
Or will a different modelemerge?
Our guest today is StuartSimpson, CEO of Think Surgical.
Stuart is in a unique positionto answer this question.

(01:34):
During his stellar 24 yearcareer at Stryker, where he rose
to become president of the JointReplacement Division, he led an
orthopedic industrytransformation that established
surgical robotic jointreplacement as a standard of
care.
Beginning with the acquisitionof Mako Surgical, in 2013.

(01:57):
He has a new challenge andopportunity at Think Surgical.
They aim to open up some ofthose closed robotic systems and
provide a tool capable ofworking with many joint
replacement devices, making itmore convenient and economical
for the clinician and thehospital.
In our conversation we discusshis roots in medical device and

(02:20):
how orthopedics became hispassion, how competition is
deeply embedded in him, thechallenges surgeons and
hospitals face with theproliferation of robots in the
OR, how Think Surgical is tryingto solve clinical, logistical,
and monetary issues, and histhoughts on how you can become a

(02:42):
stronger leader.
Here's our conversation.
Stuart, you've had a, anextremely successful career,
helping advance differenttechnologies within the
orthopedics, uh, field.
Can you tell me about how yougot started?
Tell me a little bit about thebeginning of your career in
medical device.

Stuart Simpson (03:02):
You know, I ended up in medical device
almost by mistake.
I was a sales rep for apharmaceutical company and I was
looking for my next break in mycareer.
I ended up applying to adivision of Pfizer way back in
1995.
And that was a company calledHowmedica.

(03:25):
It was a great position, greatopportunity, and underneath the
Pfizer umbrella, I mean, whatmore could you ask for?
So I went into that opportunitywith full of excitement and then
realized that, this was actuallya medical device company.
Very different from thepharmaceutical industry that I
was used to.
But very quickly I realized thatI found my home.

(03:46):
I love the tangible nature ofthe medical device industry.
I love the orthopedic industry.
And the fact that the industryand the physicians exist
together so comfortably was abig part of what attracted me to
the industry.
So I decided to stay and, a fewyears later, Howmedica was

(04:09):
acquired by Stryker, who companythat I knew very little about,
but it was the best possiblething that could have happened
to Howmedica.
It reinvigorated that business.
And I guess the rest is almosthistory.
Stryker now, as well as being abroad based medtech company, is
one of the dominant players inthe orthopaedic industry and

(04:30):
Before I knew it, Pat, 24 yearshad passed and those 24 years
were full of just incredibleopportunity.
And I look back on all of thattime with a lot of fondness.

Like you, I started off in pharmaceuticals
It didn't suit my personalityvery well.
I liked the change and, the, themedical device industry much
better.
It suited my personality better.
Was it similar to you?
Is it, was it a personalitything?
What was it about device thatwas different than pharma for

(05:04):
you?

Yeah, it was just like, as I said, it was
tangible.
You show up, you have aconversation with a doctor and
they say I'm going to use yourproducts.
You know that they use yourproducts because they take the
equipment into the operatingroom and use your product.
It's not like a doctor promisingto prescribe your drugs when

(05:26):
they see the next patient thatfits the right profile.
It's very intangible, right?
In the orthopedic industry or inthe med device industry.
When you get to a yes, it's areal yes, and I love that
accountability.
I also love the responsibility,that you have when you are
invited into the operating roomby a physician.

(05:49):
The responsibility to show up,to be well prepared and to
ensure that everything is thereto ensure a successful
procedure.
Just that whole accountable,tangible, I guess that suited my
personality type.
I like to know when I got a yesthat it was a real yes.

So you started off in sales and moved up in the
organization.
Tell me a bit, you know, some,some of the moves that you made
and why you made them.

Yeah.
Going through a colleague, I hadalways, aspired to be a brand
manager, product manager, but Irealized that the starting point
had to be in sales and successin sales was a prerequisite.
When the opportunity presentedto move into brand management, I
applied for a position as theExeter HIP brand manager.

(06:34):
I was successful in taking onthat role.
And then, honestly, I just hadan absolute ball for the next
five years as I appliedeverything I had learned about
product management, productstrategy, portfolio management
into this hit brand and thebrand was very successful in the

(06:56):
UK.
It was expandinginternationally.
So it gave me exposure to globalmarket development and brand
expansion.
it was all my dreams had cometrue when I got this position.
I was having a great time.
I was enjoying myself.
I was leveraging everything thatI had learned about marketing

(07:16):
and product strategy and in anindustry that was not just great
to be in, but was also treatingme personally very well.
So, I mean, it was, Incrediblerun that I had and then one of
my mentors in life came knockingand asked me to up my family and
move them from London toAustralia to help him with the

(07:41):
business in Australia that wasin need of some repair.
Let's just put it that way.
So I guess that was my big maincareer break when I moved down
to Australia as the Director ofMarketing.

And then from there, as you continue to move
up with, I'm always curiousbecause, some people get stuck
at some level and some peoplekeep moving up, up the line.
What was it about, about you andyour career that allowed you
those opportunities to keepmoving up?

You know, I don't know.
I think, uh, I think I embraceevery opportunity that was
given.
Um, when I look back, uh, Ialways thought, wow, I've just
got my dream job.
So I applied myself to thatdream job, thinking that was my
last job that I'd reached mysort of career ceiling, if you
like.
And then a few years later,another opportunity was

(08:35):
presented that I would look atthat and think, wow, I never
thought I would.
Absolutely.
And I would jump in and embraceit.
And I think You know, I do a lotof mentoring and I do, encourage
people to embrace what they'vegot, maximize what they're, the
opportunities at hand and justenjoy themselves.

(08:57):
Whatever happens, happens.
You can't always be thinkingabout what comes next.
You have to make the most ofwhat's here and now.

That's kind of one of the prerequisites for
promotion, isn't it?
You have to master what you'redoing today.
You have to, be successful inyour current job to get the
opportunity to get interviewedfor the second job.

Yeah, but I never thought about it in those
terms.
Like I say, there are severaltimes in my life where I've Sat
down with my wife and said, wow,I never ever imagined I would
get an opportunity to dosomething like this.
I kept breaking a ceiling that Ifelt that I had reached, not
because I was trying to breakthrough the ceiling, but just
because opportunities came myway.

How did you grow up?
Was your family, a well to dofamily?
Tell me a little bit about yourupbringing.

My father left, high school when he was 14 to
work in the mines in the westcoast of Scotland.
He was, mining coal, and thatwas the sort of community that
my family came from, but my mumwas from the same community.
So, um, we didn't really have,um, sort of very wealthy
beginning in life, but my dadwas incredibly motivated.

(10:10):
He went to night school.
He got himself a diploma.
He ended up as an electricalengineer.
He started a small company.
He then went on to work for abig company.
And, um, he then went into, uh,an international role for that
big company.
So he really sort of broke outof, very meager beginnings.
And I, and I guess that gave mea lot of the the drive that I

(10:33):
have in life, seeing what he haddone for himself and that
example was something that Itotally respected and recognized
the value of education and hardwork.
So I clad myself to educationand hard work.
It also helped that I wasincredibly competitive by nature
and I enjoyed playing sport whenI grew up.

(10:54):
I think that drive and, Innerdetermination to succeed and win
has always been part of mygenetic makeup.
What sport?
I played badminton actually, asa kid and I ended up playing
for, my country.
I represented Scotland atbadminton, but I also played
rugby through high school.

(11:15):
And, um, was in the, um, the,the senior team, in our high
school rugby team, which, lostone game in five years.

Sports is, is, is that universal crucible, isn't
it?
It's one of those things thatwe, you know, we, many of us go
through and we learn a lot oflessons that we draw on years,
decades later.

I, again, I just enjoyed the fact that I was on
the field and playing andcompeting.
That, that was everything to mein that moment, that all I
wanted to do was win whicheverparticular sport.

So let's get into, into the OR for, for a
little bit.
We want to talk about roboticsand it's going to be the
primary, topic for theconversation today, but I wanted
to start, start off from, from ahospital's viewpoint and what's
going on at the hospital andwhat is the current situation in
orthopedic devices andreplacement.

(12:11):
And when you look at it, notfrom the manufacturer's
standpoint, but from thehospital standpoint.

There's something like 5, 000 hospitals,
in the United States.
Now, and I'll limit my answer tothe US because I think it's
representative of the rest ofthe world.
So there's 5, 000 hospitals inthe US that perform, orthopedic
surgery.
On average, those, hospitalshave, anything between 6 and 10.
Let's call it an average of 8,surgeons that perform some joint

(12:42):
replacements.
There'll be some specialiststhat do a high volume.
There'll be some more generalorthopods who'll do a lower
volume.
But let's say there's abouteight surgeons on average
performing joint replacementsurgery in a hospital.
If you look at the market sharefor implants, it's, you know,

(13:02):
number one Zimmer, number twoStryker, number three DePuy,
number four Smith Nephew.
Between them they representabout 90 percent of the knee
market, for example.
So those four companies aredominant.
And by a law of averages in ahospital where eight surgeons

(13:23):
are operating, probably two orthree of them are using Zimmer,
a couple of them using Stryker,a couple using DePuy, one or two
using Smith Nephew, right?
And each of these companies havefollow the lead that was set by
Stryker and they all areoffering robots as part of the

(13:43):
package or bundle for the jointreplacement.
So, rather than using manualinstruments, the physicians are
encouraged to use a robot toimprove the accuracy and
reproducibility of the surgery.
But they can only use theimplants that come from that one
company, right?

(14:04):
in your average hospital wherethere are surgeons using each of
the different brands of implant,they're now competing, for the
hospital to buy their robotbecause they want the ho to
continue to use their, preferredbrand of implant.
And it's just not doable, Ahospital executive cannot spend

(14:26):
A million dollars per robot andbuy four different robots.
A hospital executive doesn'twant the operating room staff to
have to learn four differentrobotic systems.
It's far easier if they can justuse one.
So the executives just want thephysicians to agree on one robot

(14:47):
and therefore one choice ofimplant.
And physicians are just notprepared to do that because they
have an option to continue touse their own preferred implant.
So Um, impasse that's beencreated where physician, desire
to use robots exists, far moreso than has been satisfied

(15:10):
because this conflict that I'vejust described is very real and
hospital executives are just notprepared to purchase multiple
different robots in mostsituations.

in addition to that, you've got just the size
of the devices and how manyrooms can be tied up, and are
they mobile systems?
Can you move in between rooms?
there's, you have some practicalphysical limitations.

I would agree.
You know, you look at the robotsor something like 900 pound
pieces of equipment.
They're not exactly portable.
They take up a lot of room.
And if you've got several ofthem, they can literally take up
a full room.
So that is definitely one of thechallenges.

(15:56):
The competition to get into thehospital, which is, creating a
barrier to widespread adoption.
And secondly, once you're in thesize of these things, it is a
challenge for the hospital andtheir staff as well.

You mentioned, that there's clinical reasons
why people would embracerobotics.
It could be reproducibility, butlet's talk a little bit about,
enabling technologies and howthey can drive clinical outcomes
and also, some joint replacementis, has very high levels of

(16:32):
success, some not so much.
So how does robotics kind ofplay within that clinical
outcomes um, viewpoint?

Yeah, I think, um, what we've learned over the
last decade since, the sort ofbig move into robotics was made
by Stryker and Mako is that therobot is a very, accurate, or
precise piece of equipment.
It can, uh, guide a surgeryexactly to where, the surgeon

(17:03):
would like the surgery to.
end up or the implant to end up.
The challenge is that they haveto understand what's the target
because if you don't know thetarget you'll precisely hit the
wrong target each time, right?
And what the industry haslearned through the introduction
of robotics is that the targetfor each patient is subtly

(17:23):
different and the roboticsystems help the surgeon
understand that patient specifictarget to optimize the surgery
for each patient in theoperating room and then they can
precisely deliver that, thatsurgery.
That ends up with, a faster orbetter rehabilitation of the

(17:45):
patient.
Results in less pain and greaterfunction in the early post
operative period.
And there's even evidence thatsuggests that it leads to a
lower re operation rate andbetter outcome longer term as
well.
So there's clinical benefitshort and at least mid term to,
to using a robot.

(18:06):
But the other big thing that'sdriving the use of robots is
that Orthopaedic surgery isheavy duty.
It's physically taxing anddemanding on the surgeon, and a
busy surgeon has an incrediblephysical burden when they're
doing, six or eight proceduresin a day.
That takes its toll.
Many of them suffer from,rotator cuff injuries, or wrist

(18:29):
injuries, or elbow injuriesbecause of the physical nature
of the surgery itself.
The robot actually reduces thephysical burden.
There's a lot of evidence thatit, not only, reduces the
physical burden in the operatingroom, but that, that may extend
the physician's useful life.
So, there's a lot of, usabilitybenefits, beyond just the

(18:50):
clinical benefit, for thepatient.

I remember the first time I was seeing a redo
surgery for a heart valve andwith a redo, the way that, that,
the chest is put back togetheris you take wire basically and,
and, you know, stitch the, um,uh, the rib cage back together
sternum.
And the way that it, it getsreopened is basically with a

(19:15):
hammer and chisel.
And I remember just beingshocked, watching cardiothoracic
surgeon who is used to usingvery fine motor skills to do
anastomosis with coronaryarteries.
And he's got a hammer and chiseland he's pounding away at
somebody's chest to open up.
So yeah, there is physicalissues.

That experience is every day, every surgery for
an orthopedic surgeon.
There's the, they don't have theluxury of the fine surgical
experience that a cardiovascularsurgeon has.
Every day, every surgery is ahammer and a saw for an
orthopedic surgeon.
It's very physically demanding,taxing work.

So when you said Target, explain to me a little
bit more about Target and whatare we talking about with, minor
changes based on individuals?

A knee replacement, for example, is,
um, a bony operation.
In other words, you have to makea resection of the bone in the
right place to fit an implant.
Um, but a knee replacement isalso a soft tissue operation
because you've got fourligaments, in a knee.
You've got the two on the side,the collateral ligaments, and

(20:34):
you've got the ACL and PCL inthe middle of the knee.
And depending on the surgeon'sapproach, there may be two or
even three of those ligamentsretained during the surgery.
Each of those ligaments has gota particular tension.
so an amount that they can givebefore they get tight.

(20:56):
And to get a knee, a goodoutcome in a knee replacement
surgery, not only do you have toget the implant in the right
place for the mechanical loadthat goes through it, you have
to get the implant in the rightplace to balance the, those
ligaments when the knee bends,and that is very different.
So the mechanical alignment isthe easy part of the equation.

(21:21):
Adjusting the, the position toachieve balance through the
range of motion for eachindividual patient, that's where
it gets complex and that's wherethe robots have a It offers
tremendous advancement over themechanical instruments and it
really is different for everysingle patient.

When people hear the word robotics and surgery,
very often you think ofIntuitive as a company that has
dominated within that field, butwe're talking about a little bit
different types of systems.
So can you talk a little bitabout the difference between
soft tissue robotics and whatyou're doing?

Soft tissue robotics really is about, um,
uh, a console which is removedfrom the operating room table,
right?
So the surgeon's sittingsomewhere away from the patient
and then, using almost like agaming console to, control these

(22:23):
instruments that the robot isdirecting into the patient for
soft tissue procedures.
That has a lot of benefitsbecause of the, it adapts for
the minute movements that thephysician hand would make,
right?
So it steadies those instrumentsand makes them far more
accurate.

(22:43):
It allows the surgeon to dosurgery through a keyhole,
whereas, to do it manually, theywould have to open the patient
up.
So there's a lot there.
With joint replacement withorthopedics, it's somewhat
different.
The surgeon and the robot areboth beside the patient.
The surgeon performs atraditional, approach to the

(23:06):
knee.
So you open the knee up and thenthey use the robot to, guide.
the surgery that they'reperforming.
So the physician's no longerremote from the operating room
table.
They're standing at theoperating room table with the
robot.
They're using the robot toaugment them and to guide them,

(23:27):
not to do the work instead ofthem.
So it's a slightly differentconcept, compared to soft tissue
robotics.

So I want to take you back to your days at Stryker
for a couple of minutes.
not all of us have theopportunity to write$1.
7 billion checks, uh, but youwere involved with one of those,
uh, one of those decisions.
So take us back into what wasgoing on.
at the time at Stryker when youmade the acquisition of Mako.

Yeah, I was, involved in that whole process,
and many other people wereinvolved in that process.
And, ultimately, Mr.
Lobo, Kevin Lobo, the CEO ofStryker wrote that check.
but a lot of us contributed tothe decision.
We had looked at, our kneesystem and decided that it was
really quite contemporary andmodern and that we couldn't see

(24:24):
a way to meaningfully improvethe, outcome for patients by, a
redesign of that knee system.
We recognized that there wassomething like 1 in 4, 1 in 5
patients after a kneereplacement surgery, no matter
which brand of implant you used,were dissatisfied.

(24:44):
And we, came to the belief thattechnology, enabling technology
that would help the physician doa better job in the operating
room was probably the next majorstep forward in outcomes for
patients, rather thanincremental changes to an
implant design.
That led us into a decision,into an assessment that

(25:08):
ultimately led us to MAKO asbeing a potential acquisition
target.
And, In June 2013 we got seriousabout that and by September 2013
we had announced to the worldthat Stryker was going to
acquire Mako.
And at the point in time it was,just under$1.

(25:29):
7 billion dollar acquisition.
It was the biggest acquisitionthat Stryker had made up until
that point.
So it was a pretty big deal.
It was a privilege to be part ofthat, to be, have the
opportunity to be part of thatand even more so when, the
company asked me to, run theMako business along with the

(25:50):
joint replacement business,after the acquisition.
I guess it was kind of, um, youwanted this knife, show us what
you can do with it.

And what was that journey like?
that, that was a hugeresponsibility, but also a huge
unknown because it, you know, ithad a little bit of, uh,
traction at that point, but notthe type of traction that you
really needed to make that asuccessful acquisition.
So what was it like, developingthat, that product into a
technology that was utilized bya lot of clinicians?

The first thing is, I guess we got caught up in
our own excitement and, uh, theday we announced the deal in
September 2013, Stryker's stockplummeted.
So that was a, very quick, comeback to earth type of moment.
You know, I look back on thattime with, great fondness now,
but it wasn't so easy, in themoment.

(26:46):
we I had underestimated some ofthe obstacles that we would
encounter along the way.
I had taken some things forgranted that I probably
shouldn't have taken forgranted.
The first year particularly wasincredibly difficult.
Trying to jam Mako into StrykerOrthopedics and, I guess naively

(27:13):
going into it I thought thateverybody would see the
opportunity and understand theopportunity the way I understood
it and they would immediatelyembrace it and, that just wasn't
the case

perhaps.

When

you say everybody, are you talking about
internally as well as externallyor just externally?

Oh, I'm talking about, uh, Customers, I'm
talking about analysts, I'mtalking about investors, I'm
talking about salespeople, I'mtalking about leadership, I'm
talking about other divisions atStryker.
across the board, Iunderestimated, the sort of,
responses that, the less thanpositive responses that I would

(27:52):
get from so many differentstakeholders and, um, Was there

a common theme to their distaste for this
acquisition?
Uh,

They didn't understand it.
They didn't, think it was, theythought it was, an expensive
mistake.
And they believed that, um, itwas just what they knew it to
be, which at the time was aunicompartmental, only robot.
And what they didn't understandwas that in the background,

(28:27):
there was a total kneeapplication being developed and
our acquisition was based not onthe partial knee application
that was in the market, but onthe total knee application,
which we knew was not too faraway from market.
And our belief that wouldtransform the outcomes of total

(28:48):
knee surgery and in doing sowould deliver significant market
share gains for Stryker.
Nobody got that.
Not one of those stakeholdersunderstood that and, that's that
was on us.
Why should they know that?
only we knew that at that pointin time.
It was our job to communicatethat and to lead people to

(29:14):
understand the opportunity thatwe that we saw.
There was a lot of learning bothin terms of organizational
design, organizationalpsychology.
Also, just good communication,that we learned during that time
Fast forward to 2017, beginningof 2017 when we launched the

(29:38):
Mako Total Knee, the whole worldthen understood.
And, uh, the launch of thatproduct was one of the most
spectacular launches that thisindustry has ever seen.
And it did deliver a lot ofmarket share gains for Stryker.
So, um, you know, thankfully wegot there.

You had a smile on your face, you had a smile,
you had a smile on your facewhen the product launched and
you had a lot of, uh, bruises onyour back, uh, when you were
there as well.

Thankfully we got there, but it wasn't without
pain and strife.
I'm just grateful there were acouple of, great people above me
that, believed in me and,allowed me the opportunity and
time to figure it out.

So that, that, acquisition also kicked off some
activity within the competitivelandscape, too.
The competitors hadopportunities or had issues when
you were the only one out therewith this robotic platform.
So what was the competitiveresponse?

Yeah, very quickly, um, Smith and Nephew
acquired the other obvious,technology.
It was called Bluebelt at thetime, so they acquired that.
Much later, several years later,Zimmer, uh, eventually conceded
and acquired Rosa, which was aFrench company that had a robot

(31:08):
in the sort of cranial space,which could be adapted to knee
replacement.
And then eventually the last oneto the party was Johnson Depew,
who acquired a company calledOrthotaxi and then developed a
robot called VELUS which theylaunched, I think, 2020 ish.

(31:31):
Now all of the companies are inthe market.
They all have a total knee robotand they all offer a combination
of my robot and my implants.
An exclusive, combination.
So a razor, razor blade typemodel.
When Stryker were the only onesoffering that, the market was
prepared to, change or switchfrom their preferred implant to

(31:55):
the Stryker implant to getaccess to the technology.
Now that they're all doing thesame, nobody's prepared to give
up their preference, which hasled to this big sort of status
quo, or impass in the marketwhere there's a lot of
physicians want to, use robotsfor joint replacement.

(32:15):
There's hospitals that areprepared to buy robots for joint
replacement, but are not buyingthem in the quantity you would
expect because of this conflictand this inability to, select
just one.
So that's created theopportunity for Think Surgical.
And that's why, ultimately.
that's one of the two reasonsthat I decided to come and take

(32:37):
on this opportunity to work atThink Surgical.

Do you have an, an Apple phone or are you a,
Android person?
I have an Apple phone.
Apple phone.
So, you know, all about closedsystems.
So all of our listeners outthere know about closed systems.
You think about, you know, Appleis a closed system.
And a lot of these, as we said,the big four have closed systems
as well.
It sure would be nice to have anopen system.

(33:03):
So let's talk about ThinkSurgical and what you guys are
doing.

when I left Striker, I was approached about
becoming the CEO at ThinkSurgical and my knowledge of
Think Surgical, dates back to aproduct, which really is, was
the first robot in surgery, orat least in orthopedic surgery,
it was called RoboDot.
And that was from the 90s.
And um, it was ahead of itstime, a real, incredible

(33:29):
innovation, but just ahead ofits time.
The world wasn't ready for it.
This company, Think Surgical,had a more modern version of the
Robodot platform, but to behonest, I didn't rate it.
There were several things aboutthat I didn't like, didn't view
as competitive.
So my immediate reaction was, nothank you, I'm considering other

(33:52):
opportunities.
But somebody that I know andrespect and trust, over there
said please just come and lookat something, that you're
unaware of.
Something that's in development.
So I went over there, and theytold me it was a handheld robot,
and I had absolutely no ideawhat that meant.

(34:13):
I couldn't conceive of what thatwould be, what it would look
like, or how it would even work.
so I was somewhat sceptical.
I went to see it, I put my handson it, and the moment I saw what
this device was capable of, thelight bulb went off.
And I realised that this was,something that could, really

(34:34):
make a big impact in the market.
Could make robots accessible tothe majority, if not all of the
market.
Whereas the old systems werereally Yeah, complex to use.
So they were really forinnovators and early adopters,
not for the majority of themarket.
I saw this as being a massmarket, a product with mass

(34:56):
market appeal, and that reallygot me quite excited.
And then secondly, Think are arobot company.
They are not an implant company.
They will never be an implantcompany.
If they acquire an implant,they'll end up competing with
the big companies on, like forlike terms and they'll get

(35:17):
beaten, right?
There's just no way that wecould be successful.
So we are a robot only company.
We live and die by the successof our robots.
In other words, if we can createa good customer experience with
our robots, And get them to usethem more often, then we'll be
successful.
And if not, we won't.

(35:39):
Whereas the big companies,they're really implant companies
first and foremost.
All they care about is sellingmore implants.
And if a robot can help themsell more implants, great.
But they don't live or die bythe quality of their robot and
their robot offering.
And that's where I think we havea competitive advantage because
that's all we care about.

(36:00):
And we are agnostic.
We will put any implant on ourplatform that wants to come on
our platform.
And the value proposition isvery appealing if you're a
hospital executive, who does notwant to, sign up for restrictive
contracts that obligate them topurchase certain volumes of

(36:24):
implants from one company for aperiod of time at a
predetermined price.
They want the ability to, makedecisions on a, um, You know,
quarter by quarter, year by yearbasis about what supplies
they're going to purchase andhaving a robot that supports all
implants is ultimately betterfor the customer.

(36:45):
So, that's our mission, tobecome that, robot that can
support all implant companies.

Well, I want to go deep into that because
there's so much there with, um,the objective of different
companies and how they go.
But, but, but before we gothere, can you describe you say
handheld, can you describe forthe listeners what we're talking
about with a handheld system,size, shape, how that works?

Like most people, I have a pre, or I used
to have a preconceived idea ofwhat a robot was.
a robot was a big base unitwith, an arm, an industrial arm
that came out the top of it.
But then moved in five, six orseven degrees of freedom to give
it dexterity.
And then at the end of that arm,there was something, a tool that

(37:40):
would, in the case oforthopedics, help with the bone,
resection, right?
So a drill or a saw or a burr orsomething like that.
And, that's how, if you look atthe industry, that's obviously
how everybody else thinks aboutit.
They think about a base unit andan arm and an end effector.
But one of the engineers, atThink Surgical, a guy called

(38:01):
Joel Zuhard, thought about itdifferently.
He looked at what the surgeonwas trying to achieve.
in the operation and then workedbackwards from there and that
led to a handheld device thatautomatically adjusts for the

(38:22):
surgeon's hand movement andensures that it hits a
predetermined exact target forguides that then guide the rest
of the operation.
And, um, you know, you've got tothink about it, it's almost like
a handheld gyroscope, right?

(38:42):
It's a free floating mechanicalunit within a handle.
As your hand moves, the device,the powered device, adjusts to
your hand movement, but stillmaintains an exact target on the
patient's bone.
And it is quite amazing when,what we give surgeons the
opportunity to, try it for thefirst time.

(39:06):
There's this look that you seeon their face where they're just
like, they suddenly get it.
And it takes me back to my firstexperience.
I could not understand what itwas all about.
Until I felt it, until I saw it,until I experienced it for
myself.
So that's in an, in a nutshellwhat it's like.
It's about seven pounds inweight compared to the, existing

(39:28):
robots, which are about 900pounds.
So we just made like 893 poundsredundant.
And it sits on the operatingroom table where all the other
instruments normally sit.
So there's no, disruption to theworkflow for the surgeon and the
OR staff.

(39:50):
Whereas when you use one ofthese other robots, the surgeon
and OR staff have to move out ofthe way, let the robot come in.
And then you have to work aroundthe robot, uh, it can be very,
very difficult and challengingand most OR staff actually don't
like it because it completelydisrupts their workflow.
Ours just comes in and sits onthe sterile table and when the

(40:13):
surgeon needs it, he picks itup, uses it.
And when the surgeon is donewith it, she puts it back down.
So it's, quite, quite adifferent experience.

So this looks like a, like a hand drill, you
know, we've all used them.
It's a larger seven, sevenpounds,

Yeah.
I mean, exactly.
I'm not very dexterous, but Ican use it successfully with my
left hand or right hand.
No problem.
And, that's the, that's what wehear from, physicians to get
used to it.
they're just amazed at how ittakes over and does its thing,
as long as you keep it in moreor less the right, area around

(40:47):
the knee.
And if you move outside of that,Correct area.
It just it powers off.

So the name of the product is T mini But you
also have another product Tplan.
Can you tell me a little bitabout that?

The most accurate way of performing
robotic joint replacementsurgery is to start with a CT
scan, a three dimensional imageof the patient's actual anatomy,
rather than relying on sometheoretical model for a knee
replacement rather than relyingon just an x ray.
Three dimensional, image of thepatient's knee.

(41:24):
It goes into T Plan.
T Plan, takes the CT informationand turns it into an actual 3D
model for that patient.
And then allows our, Think caseplanners to, plan the, right
size implants and put them inapproximately the right location
for that patient.

(41:45):
That is then transmitted to thesurgeon who, either confirms
that that's the right surgicalplan for that patient or can
make some adjustments to itbased on their their surgical
experience or their individualknowledge of that specific
patient.
Ultimately, they sign off onthe, the surgical plan and then

(42:06):
it's made available to be loadedonto the robot.
So that, that's T Plan.
Having a platform like that isimportant to us, not just as a
communication, platform with thesurgeon, but ultimately we're
going to add more robots.
We'll add more complex robots,we'll add robots for different
applications.
We'll even add an autonomousrobot, probably at the end of 24

(42:30):
or early 25.
We want to have this ecosystemwhere it's a single planning
solution, no matter which robota physician ends up choosing.
So T Plan is that.
That's our, if you like, ouriTunes.
When you use the Apple analogyearlier on, T Plan is our
iTunes.

(42:50):
And that's where All thedifferent implant models will be
stored so that the surgeon canchoose whichever brand of
implant they want to use becausethey're trained to use it.
Or, increasingly, they mightchoose a different brand for
each patient because there are,certain things about each
individual patient that maybemake them better suited to one

(43:11):
model versus another model.

Anyone who's been in orthopedic surgery before
knows that, it's not only theimplant, but there's a lot of
instrumentation that comes in.
Tons of instrumentation thatneeds to be sterilized, put in,
and make it made available.
and sometimes you have to moveit between hospitals, etc.
Does having, um, moreinformation at the planning

(43:35):
stage affect the amount of toolsthat you need to bring into that
surgery.

Absolutely.
And it's a great point.
Because you have a CT scan, youknow exactly what size implants
are required for that patient.
If you're not using a robot,you're using a manual system.
It's like Meccano, the surgeongoes into the operating room
with all of the different,components available and then

(44:03):
sizes it during the procedureand then chooses the right
parts, for the patient.
With, a CT based, robot, youknow exactly what, parts you're
going to need before you go in,which gets rid of all those
different sizes, from thesystem.
And! The robot replaces 80percent of the alignment

(44:26):
instruments used during theprocedure, so you get rid of all
of them as well.
Which means that the surgeononly needs our T mini, plus, a
handful of other instruments.
to perform the whole operation,whereas, with manual cases, that
might be six whole trays ofinstruments, which have a

(44:46):
tremendous cost and operationalurgent burden for the hospital.
So you're starting to point onone of the, sort of, um, the
efficiency, benefits that comefrom robotic surgery, and I
appreciate you highlighting it.

You've got a system that a surgeon could
really like.
Oh, this is fantastic.
Solves a lot of my problems.
Does it work with the Strykerknee that I like?
Does it work with the Smith andNephew?
So now we get into this.
Who's your customer issue?
Is your customer the surgeon oris your customer the company?

Yeah, my first customer is the Implant
Companies, and it's a verydifferent place I find myself in
compared to the last 24 years,or 24 years that I was at
Stryker.
You know, I used to go to thesetrade shows and look across the
exhibit halls at the othercompanies and, eye them up like

(45:45):
you would eye up the opposingteam in a rugby game.
You know, they were mycompetition, they were there to
be beaten, respected, but alsobeaten.
And, um, now I find myselftreating them as customers.
And, we have four of the smallercompanies in the market on our

(46:06):
platform at the moment, butyou've asked the right question.
If and when do the big companiescome onto your platform?
And, I can tell you that there'sa lot of, openness within those,
companies to have theseconversations.
And, I believe most of themrecognize that the customer

(46:26):
wants an open platform and theyhave to figure out whether
that's 1 percent of the marketor 10% of the market or 30% or
more.
If it's only 1%, they can, theycan choose to ignore Think
Surgical, they can choose toignore me and, nothing bad will

(46:48):
happen.
But if it becomes 10, 20, 30 ormore percent of the market
decide that open platform istheir preference, then those big
companies have to make adecision about either walking
away from that segment of themarket, which means seeing their

(47:09):
growth rate slow or decline, orthey have to, uh, embrace with,
Think Surgical.
So we're in that period of timewhere we're all trying to figure
out how big is this segmentgoing to be.
I happen to believe it will beas much as a third of the
market.
And, I believe that the bigcompanies will have to

(47:31):
participate at some point intime.

Stuart, you're in a really unique position in that
you made the first acquisitionand made it a closed system.
And now you're advocating for,yeah, but now you're advocating
for an open system.
And those decisions are not, um,they're not wrong.

(47:56):
I mean, it was a right decisionat that point in time.
And it may be a right decisiontoday.
So it's not a mutually exclusivething.
So how do you view things?
You know, why is it, why has itchanged so much, you know, six,
eight years later, you know,since when Mako first went in to
where it sits today, what'sreally changed to, to make this

(48:16):
an opportunity for you?

Yeah, a couple of things.
Um, we can say with some degreeof certainty that it was the
right thing for Mako, andStryker at that time.
They had just spent a tremendousamount of money on the
acquisition.
They had put their reputation onthe line individually, people
like me and others, as well as acompany.

(48:40):
And, the whole strategy wasgeared around leveraging, market
share for the Stryker and EMplan.
Between 2013 when the dealclosed and 2022, so a 10 year
period, Stryker's, knee marketshare in the US increased nine

(49:01):
percentage points, and that'sunheard of in, um, the
orthopedic market.
Zimmer Biomet lost six pointsand Depuy Synthes lost three
points.
Stryker were the, um, netbeneficiaries of all of that.
And, um.
so that, that is, that wasdefinitely the right thing to

(49:22):
do.
Being an open platform, solutionright now for Think Surgical is
not proven.
We still have to prove it out,but it is the right thing for
this company.
We cannot compete with those bigcompanies head to head with the
the same business model thatthey have.

(49:42):
We will just get beaten.
so we have to try and, offer thecustomer something that they
value that they cannot get fromthose big companies.
And those big companies are notgoing to open their robots up to
become agnostic open platforms.
They've got too much to lose.
So that's something that we cando at Think Surgical, and we

(50:05):
believe there's a tremendousamount of customer value in
doing so.
There's a couple of reasons forthat.
First of all, actually thesmaller companies in orthopedics
are where a lot of the bestinnovation occurs.
It's where the fastestinnovation occurs.
The big companies are playingnot to lose.
They've got too much to lose.

(50:27):
Therefore, their innovationcycle is much, much longer.
The smaller companies caninnovate much quicker and lots
of them have really more modernin plant solutions.
But because the big four haverobots, you now cannot compete
without a robot.
So we offer the opportunity forall of those other companies to

(50:51):
compete.
So that's a value.
Secondly, as I've said earlier,the customer wants to invest in
one robot platform for severalreasons.
First of all, they want theirstaff to learn one solution.
They want to be able to use thatsolution to treat all patients.
If they can do that, they canimprove quality and efficiency.

(51:11):
If they can, support allimplant, different implants on
that one system, they get higherutilisation.
Higher utilisation means abetter return on investment for
the customer.
Um, capital they've spent on therobot.
So there's economic benefits tothe customer as well.
And ultimately, um, havinginnovation and competition as a

(51:34):
customer is good for you, right?
There's every healthy, Industryhas innovation and competition.
At the moment, the industry's atrisk of losing innovation and
competition because the fourcompanies have got the market
locked up and they're all doingthe same thing.

(51:54):
There really isn't muchinnovation.
There really isn't muchcompetition.
And, that's why I believe thatdoing it this way, not only is
the only way for THiNK to besuccessful, it's the right thing
to do.

Well, I always look at it from the customer's
standpoint.
What is best for the customer?
And we, very often do thingsthat are not best for the
customer.
If we're not collaborating withour competitors, um, and making,
you know, same thing,instrumentation.
How many instruments have to gointo an OR and get sterilized?

(52:30):
As you said, you have to knowwhy I'm putting a Stryker knee
in today, but maybe it might bebetter to have somebody else's,
which means, you've got to holdanother set of instruments and
needs, needs to head into that,uh, into that OR.
Not necessarily a good thing forthe, for the people at the
hospital, but man.
It's a good thing for thecompanies.
You know, they're not.
So, so really if you look at itfrom the customer standpoint,

(52:53):
what's, you know, that's whatwe're supposed to be in business
for, we're supposed to be inbusiness for helping the
customer, making their jobeasier.
And when we put things in thereto protect ourselves and make
our own selves money, yeah,there's, there's that
consideration, but don't tellyourself that you're in it for
the customer.

(53:13):
When you do that, because you'renot, it's just, it's a, it's a
profitability question thatneeds to be answered, but don't,
don't fool yourself becauseyou're not fooling your
customer.

You said that, not me.
I happen to, I happen to agree.
Um, you asked me what changedand what's changed is that the
other companies are now doingthe same thing as Stryker.
When Stryker was the only robotgig in town.
It was appropriate to say youwant access to a robot, use our

(53:48):
implant.
but once it became the, the, ifyou like, the standard business
model for the whole market, itjust doesn't work.
Think about it, in terms of,cars.
And we see this play out in realtime with different electric
vehicles having differentchargers.
There's no way that countriesaround the world, governments

(54:09):
around the world, are going toinvest in multiple different,
charging stations to supportdifferent, plugins.
Right?
Eventually, common sense has toprevail for the, benefit of the
customer.
There needs to be a standard.
And then you compete with yourown individual brand of car
after that.
That's an analogy with whatwe're trying to do here.

Even Apple changed their charging cable
with the last iPhone.
They held on for a long periodof time, but then governments
and customers came out and said,no, you've got to change this
thing.

Yeah, exactly.
So, that's where we're at.
It is interesting, you know, theirony is not lost on me that I
was at the forefront of onestrategy and now I'm at the
forefront of the oppositestrategy, but times have
changed, the market has changedand the competitive environment
has changed.

Absolutely.
So I want to finish, finish offhere today, talking about, uh,
teams because you've been reallysuccessful, in your career, but
you haven't done it by yourself.
You've, you've, uh, surroundedyourself with some great people.
along the way.
And you've had the opportunityto kind of look at success and,

(55:28):
you've managed, and been aroundvery successful, people in the
past.
What I wanted to find out fromyou is, are there some common
traits, some common things thatyou've picked up with successful
people that, that you've workedwith and are those things that
we should look to develop aswe're developing our careers?

The people that I have worked with along the way
that have impressed me either aspeers, as, people ahead of me or
above me, or people on the teamsthat I'm responsible for.
The people that, um, stand outfor me are the people who just
know who they are and know howto make the whatever it is they

(56:13):
have in life or in theirpersonality.
The combination of their owninnate, abilities, with their
own set of experiences that theyknow how to leverage that to
maximum effect.
As a young, person in theindustry, stepping into
management for the first time, Ireally had the, great, privilege

(56:34):
of working for two verysuccessful leaders, almost at
the top of, you know, very highup in the, the organization and
the two of them could not havebeen more different and being a
kind of curious and inquisitivetype of person, I found myself
thinking, why does that work forthat one?
Why does that one do that?

(56:56):
And why does it make an impact?
And then I found that, notdeliberately, but just, over
time, I was taking bits fromeach of them that I felt
comfortable might work well forme.
And there were certain thingsthat each of them did that I
thought, there's no way I couldever do that.
That just wouldn't be genuine.
It just, it's not who I am.

(57:16):
So I guess in my own way I waswalking through life and trying
to figure out how to becomebetter each day by watching what
worked for others and selectingthe things that might work for
myself.
So the people that I've beenmost impressed with in the
career are people who do that.
They've figured out what worksfor them and what doesn't work

(57:38):
for them, how to use theirstrengths and talents.
And experiences to maximumeffect.
And they're just genuine.
This is who I am.
I'm the same person at home as Iam in the office.
It's just who I am.
And there are too many peoplethat you come across in the
industry that try very hard tobe one particular persona at

(58:04):
work and a completely differentpersona away from work.
And you know that the persona atwork is not really who you are.
And, those types of people whogive off a sort of energy that's
relaxing, it's motivating, it'senergizing, it's all of those
things.
And it leads, other people towant to be around them and to

(58:24):
follow them and to be part ofwhatever it is they're doing.
The other major trait that, I'veidentified in people that I
respect most is a healthy levelof self doubt, of, not

(58:44):
insecurity, but recognizing thatthey're not invincible, that
they don't have all of theanswers.
Particularly if you combine thatwith some self assurance or
confidence to be able toarticulate that in front of
others.
but, I've, I'm also always waryof people who give off that sort
of energy that, you know what, Ican do anything, doesn't matter

(59:06):
what somebody throws at me, ofcourse I'll be successful.
Because the reality is, greatleaders understand when they're
stretching.
And they understand that theydon't have all of the answers.
And they know they need to reachout to others for help.
And they recognize that, theymight not make it.

(59:26):
And I think that helps drivethem forward and helps, with
their success.
So I think some humility, selfawareness.
are key characteristics ofsuccessful people that, that
I've, come to respect in mylife.
And the last thing is and thisis a watch out for big
companies.
and I see it more now than, Iused to when I was part of a big

(59:50):
company.
Big companies have a tendency toput people in boxes.
you're that guy, you're thatgirl, you're that person, right?
You're that great sales person.
you're one of the best, we'dlove to pay you a lot of money
and we hope you keep doing that,but you're just a salesperson, a
great salesperson.
But just a salesperson and, I'veseen people too often put into

(01:00:14):
those boxes and big companiesand not given the opportunity to
flourish and grow and take onnew experiences.
And, thankfully, I'm in aposition now where I have a
platform.
to hire some of those people,that are in boxes and big
companies to come and flourishand grow here.

(01:00:34):
And I have a, I have severalexamples of that at the moment
and it's working out real well.
and that in itself creates atremendous amount of, positive
energy.
When you see people who used toactually allow the companies to
define them in a box, Suddenlyrealized that the world and

(01:00:55):
their capabilities are so muchbigger than that box.

Patrick Kothe (01:01:00):
What a great discussion.
Stewart's had so much success inour industry.
And we just heard he's taken onanother challenge.
I'm so happy to share thisdiscussion with you.
So you can hear how an industryleader thinks about change.
And where the business will begoing.

(01:01:20):
A few of my takeaways.
Number one.
Stuart is a competitor.
You could hear it in his voicewhen he described his early days
in sports, representing Scotlandin badminton, rugby in high
school.
But more importantly, when hestarted discussing it in
business.

(01:01:40):
Or he would go to trade shows aneye up is competition.
And then he said they were thereto be beaten.
Respected.
But beaten.
There's no doubt that Stewart isa competitor to his core.
The second thing is when is theright time to recognize that a

(01:02:02):
product or system.
Uh, that we have benefits usmore than it's benefiting our
customer.
And then how do we transition tosomething different?
So we discussed what Stryker didand what Stuart did with the,
with the Mako product in theearly days of RO robotics.
And it was appropriate at thatpoint in time.

(01:02:23):
But the market is changing.
Customers are frustrated.
And it may require a newstrategy.
Some of the companies that areout there with robotic system
need to take a look at thiscarefully and any of us who are
in a business where we do thingsone way, and we find that at
some point in time, it'sbenefiting us more than our

(01:02:45):
customers.
We need to look at that and say,is it time for a new strategy?
And one of the things that hediscussed is what is your core
business?
His core business is robotics.
Joint replacement companies,their core business is joint
replacement.
So sometimes that kind of leadsyou to the answer that you're
going to need, need to a.
need to.

(01:03:05):
Uh, implement.
But in the longterm, the winnersin this are going to be those
who will focus on satisfyingtheir customers.
The last thing that I reallyenjoyed hearing about was his
views on, uh, what makes peoplesuccessful.
And he discussed two things thatI think are very important or

(01:03:28):
important to me as well.
Genuine, and humble.
And on the genuine side, hesaid, observe, observe what
others do.
And embrace what's right foryou.
But discard, what's not genuineto you.
So even though it may work forsomebody else, else, if it's not
genuine to you, it's not usefulto you.

(01:03:49):
So embrace what's right.
And discard, what's not genuineto you.
And then he discussed beinghumble, having a healthy level
of self-doubt.
Not insecurity.
But self-doubt.
Be humble.
Great words of advice.
Thank you for listening.

(01:04:10):
Make sure you get episodesdownloaded to your device
automatically by liking orsubscribing to the Mastering
Medical Device podcast whereveryou get your podcasts.
Also, please spread the word andtell a friend or two to listen
to the Mastering Medical Devicepodcast, as interviews like
today's can help you become amore effective medical device
leader.
Work hard.

(01:04:30):
Be kind.

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Open or Closed Robotic Systems – Are We at a Crossroads? Featuring Stuart Simpson

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Open or Closed Robotic Systems – Are We at a Crossroads? Featuring Stuart Simpson