From Idea to Market: Ep 9 - Inside the Decision Room

What med tech investors and strategic acquirers actually evaluate when a founder walks into the room — and what separates the pitches that earn capital from those that don't. A conversation drawn from people who've sat on both sides of the table.

For nine episodes, the From Idea to Market series has followed innovation from the founder's perspective — the problem noticed in a clinic, the iteration through years of prototypes, the regulatory climb, the manufacturing scale-up. Episode nine flips the lens. For the first time, the conversation moves into the room where decisions about that founder get made: by investors, by strategic acquirers, by the people whose capital and reputation come along with a yes.

Joe Schwab is joined by voices who've lived this evaluation from every side. Charles Lawrie is a co-founder and chief medical officer at FIOS Health and the current president of the Anterior Hip Foundation. Charlie DeCook is the president of Total Joint Specialists and has watched dozens of Shark Tank pitches at AHF annual meetings. Alex Sah is past AHF president, chief medical officer at Think! Surgical, and chief innovation officer at Ospitek. Robert Cohen, vice president of innovation and technology for Stryker's orthopaedic group, has spent four decades evaluating med tech ideas from inside startups and from inside one of the largest companies in the field.

The episode unpacks three questions: what truly drives the decisions made behind closed doors, how clinical value and financial logic and strategic interest actually intersect in real time, and which kinds of narrative survive due diligence — and which collapse the moment scrutiny begins. For surgeon-founders preparing to pitch, for clinicians thinking about their first innovation, and for anyone curious about how med tech capital actually gets allocated, this episode lays out what the decision room is really testing.

⏱️ Chapters:

00:00 Why this episode flips perspective from founder to investor

02:42 Surgeons and industry leaders inside the med tech decision room

04:46 What investors actually look for in a med tech pitch

08:23 How to structure a 15-minute med tech pitch

13:30 Where clinical value, profit, and strategy intersect

15:30 Why a great med tech idea can fail to scale

18:36 Why founders should pitch with a CEO at their side

22:02 How honest narrative wins under due diligence scrutiny

26:40 Stick to your competency: advice from a Stryker VP

29:12 What the decision room is really testing

31:43 Preview: when scaling success threatens to break the company

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This podcast is intended for educational and informational purposes only.

The content discussed does not constitute medical advice and should not be used as a substitute for professional judgment. Clinicians should rely on their own training, experience, and clinical decision-making when applying information from this discussion.

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Transcript

Joseph M. Schwab 0:21

Hello and welcome to the AHF Podcast. I'm your host, Joe Schwab. From Idea to Market is a series about how medical innovation actually happens, not just how ideas are born, but how they're tested and shaped and ultimately judged. If you're just joining us, I highly recommend pausing and going back to the beginning of this series. Each episode builds directly on the one before it, and what we're about to discuss only really makes sense with that foundation behind you. Up to this point, we've followed the journey almost entirely from the founder's perspective. A problem noticed in a clinic or an idea shaped through years of iteration. A company built, funded, and cleared. And in episode eight, we learned about the hard work of manufacturing at scale. Well, this episode flips the lens. For the first time in this series, we step out of the founder's perspective and into the room where decisions about that founder get made by investors who have seen hundreds of pitches and by strategics evaluating whether a company fits their portfolio and by people who have been on both sides of that table and understand what each side is really looking for. ​​In this episode, you're gonna hear from people who understand what happens when an idea meets serious scrutiny. Founders who have pitched to rooms full of skeptics and come out the other side, or surgeons who've evaluated ideas in real time, in public, on stage, and leaders who have sat in acquisition rooms and decided which companies were worth hundreds of millions of dollars and which weren't. Rather than introducing them one by one, I want you to hear them first in their own words.

Charles Lawrie 2:42

I'm Dr. Charles Lawrie. I'm the co-founder and chief medical officer of FIOS Health. I'm also a high volume, anterior approach hip replacement and robotic knee surgeon in Miami, Florida, and, uh, current president of the Anterior Hip Foundation.

Charlie DeCook 2:56

My name is Charlie DeCook. I'm the president of Total Joint Specialists, a 17 surgeon group here in Atlanta, Georgia.

Alexander Sah 3:03

My name is Alex Sah and I'm a hip and knee surgeon in private practice as medical co-director of the Institute for Joint Restoration in Fremont, California. I was past president of the Anterior Hip Foundation and currently serve as Chief Medical Officer at Think! Surgical and Chief Innovation Officer at Ospitek.

Robert Cohen 3:19

My name is Robert Cohen and I am a mechanical engineer that have worked in the med tech industry for over four decades, and I presently am the Vice President of innovation and technology for the Orthopedic Group at Stryker.

Joseph M. Schwab 3:34

Together, their stories help us understand what the decision room actually demands, not just from the idea, but from the person presenting it In this episode, we look for answers to three questions that define what happens when an innovation enters the room where decisions get made. First, what truly drives decisions behind closed doors? Second, how do clinical value, financial logic, and strategic interest intersect? And third, which narratives gain traction under scrutiny and why? Because support from an investor or a strategic is not simply, "We like your idea." It's, "We're willing to put our capital and our reputation and our time behind you," and that is a different standard entirely. This is chapter nine: Inside the decision room. There's a tendency to think of pitch meetings as a performance. The slides and the demo and the time limit, the rapid-fire questions. From the outside, it can look almost theatrical, but from the inside, a pitch meeting is a risk filter, and the people running that filter aren't evaluating enthusiasm. They're evaluating judgment. They're asking, "Does this person understand the problem they're solving? Do they know what they don't know? And can they be trusted when things go wrong?" Because in med tech, things go wrong. Well, the answers to those questions are rarely in the slides. They are in the way a founder responds to pressure and in the choices they made about what to include and what to leave out, and in whether the story they're telling is internally consistent from the first minute to the last. So let's start with the first question. What truly drives decisions behind closed doors? Before we talk about what happens in the room, it helps to understand what the people in the room already know before the founder walks in. A serious investor or strategic evaluator in med tech has typically seen dozens and sometimes hundreds of pitches. They've watched companies with strong clinical rationale collapse under manufacturing pressure. They've watched technically elegant devices fail because the reimbursement pathway was never addressed. They've watched founders who believed so deeply in their product that they couldn't accurately describe its limitations. And they've watched the opposite: founders who were so measured and self-aware that the room moved toward them before the presentation was over. Well, that accumulation of experience shapes the way decisions get made. It creates pattern recognition, and it means that what gets evaluated in the room isn't just the product, it's the founder's model of reality. How accurately does this person see their own situation? Research on investor decision-making in early-stage companies consistently finds that the founding team is rated as the most important factor in investment decisions, ranked above market size and product differentiation and business model, not because the product doesn't matter, but because in an early-stage company, the team's judgment is the product's best proxy for quality. The product will change. The team's ability to navigate change is what actually determines outcomes. Robert Cohen has spent four decades evaluating innovation from inside startups and from inside one of the largest med tech companies in the world. And when he describes what he listens for in a pitch, what stands out isn't the sophistication of the technology, it's the structure of the thinking.

Robert Cohen 8:22

if you have 15 minutes and a 15 minute pitch, the first five minutes is what problems you're solving and why the market may be ready for this. The next five minutes should be about what the device is and why the invention is so good. And the last five minutes of what it takes to get to market. Is there huge regulatory hurdles where it needs clinical data supported? Can it get a 510K Class II designation in the United States relatively quickly?

Joseph M. Schwab 8:51

The structure Robert describes isn't a presentation tip. It's diagnostic. It's a founder who leads with the problem before the solution, before the technology, before the excitement. It's something demonstrating that they understand where value comes from. It comes from solving something real. The device is the vehicle. The problem is what matters. That sequence, problem, solution, path to market, maps directly to how investors assign risk. Market risk is the largest category. Is there actually a problem worth solving here? And is the market ready for a solution? Technical risk comes second. Does this device actually do what it claims? And then execution risk. Can this team navigate the regulatory and commercial and operational obstacles between here and revenue? A pitch that follows this order isn't just organized, it's implicitly addressing the investor's risk hierarchy in the same sequence the investor uses to evaluate it. That alignment is in and of itself a signal of judgment.

Robert Cohen 10:12

15 minutes is a long time to explain. If it's just the concept, you have to do your p and l. You don't have to tell me about your cashflow. I don't even have to get necessarily into your supply chain. Just focus on that focus, focus, focus, and you will have our attention.

Joseph M. Schwab 10:26

Focus is a word that comes up again and again in conversations with experienced evaluators, and it's not a stylistic preference. In due diligence, which is the formal process by which investors and acquirers examine a company before committing capital, the ability to focus is actually a proxy for operational discipline. A founder who can't prioritize what matters most in a fifteen-minute pitch might have the same difficulty prioritizing what matters most in a clinical trial or a regulatory submission or a manufacturing decision. The research on med tech due diligence is consistent, at least on this point. Investors and acquirers report that the most common red flag in early-stage pitches is not a flawed product. It's a mismatch between the founder's confidence and their understanding of the obstacles ahead. Founders who acknowledge risk clearly, who can say, "Here is what we know, and here is what we have not yet proven," consistently perform better in due diligence than founders who minimize uncertainty in the pitch and are then exposed by it during review So here's our first answer. What drives decisions behind closed doors isn't the quality of the slides or the enthusiasm of the presenter, it's the accuracy of the founder's model of their own situation. Investors are listening for clarity about the problem and honesty about the path and evidence that this person's judgment can be trusted under pressure. Those signals come through in the first fifteen minutes, and they determine whether the conversation continues. But clarity and structure alone don't close the room. Once a founder has earned attention, a second and more complex evaluation begins because the people in the room aren't all asking the same question. An investor is asking, "Can this generate a return within my fund's timeline?" A strategic is asking, "Does this fit what we're building, and does it strengthen our position in the market?" A clinician evaluator is asking, "Does this actually make patient care better?" Well, those three questions can point in the same direction. They can also point in three very different ones, and the founder's ability to speak to all of them simultaneously without losing coherence is one of the most demanding things the decision room requires. That brings us to question two: How do clinical value, financial logic, and strategic interest intersect? There's a common assumption among clinician founders that if the clinical value is strong enough, the financial and strategic case will naturally follow. The logic seems reasonable. Better outcomes reduce costs, reduced costs improve economics, and improved economics attract capital. But that chain of reasoning, which while often true in principle, rarely survives the decision room without active work because clinical value and financial value operate on different timelines And they get measured in different units, and they're evaluated by different stakeholders who don't always communicate with each other before a decision is made. A payer measures value in cost per episode and reduction in readmissions, but a hospital may measure it in throughput or OR utilization or case profitability. But an investor measures it in defensible IP and time to revenue and exit multiple. A strategic acquirer measures it in how well the technology fits their existing profile, as well as their sales infrastructure and their long-term clinical roadmap. None of these people are wrong. They're all applying the correct evaluation framework for their role. But the founder who walks into the room prepared only to make the clinical case is likely to be surprised by the questions that follow. Alex Sah has both developed med tech products and evaluated pitches in a structured setting that brings exactly this multi-stakeholder reality to the surface. He describes what becomes visible when ideas face a room of experienced evaluators from different angles.

Alexander Sah 15:30

The Shark Tank at the Anterior Hip Foundation has been one of the most popular segments of our annual meeting, and you learn so much just by seeing how great ideas may have benefit or may have some. difficulties, Coming to market, it might be the world's best idea, but it's just too difficult to spread across adopters or maybe doesn't have the return on investment. It's really interesting to hear that perspective. To be able to hear from these, uh, very, uh, important executives and decision makers at large companies of, of what they see the market is today and tomorrow.

Joseph M. Schwab 16:02

That phrase, too difficult to spread across adopters, is doing a lot of work because it's not a clinical statement. A device can be clinically excellent and still fail to spread because the training burden is too high or the workflow change it requires is too disruptive, or because the reimbursement code just doesn't exist, at least not yet. These are not reasons to abandon an innovation, but they are obstacles that have to be anticipated and named and addressed before the room will take the financial case seriously And the financial case has to be made explicitly. Research on med tech investment decisions consistently shows that investors expect clinical benefit to be translated into economic terms, not left as an implied benefit. A product that reduces PJI rates by 50% is compelling. A product that reduces PJI rates by 50% while lowering per-patient episode cost by an estimated $80,000 across a market of 30,000 affected patients annually is a business. Those are different conversations. Alex is direct about what the evaluation ultimately comes down to, and it's a point that clinician founders sometimes resist, but that experienced evaluators treat as foundational.

Alexander Sah 17:35

these good ideas have to be profitable. I mean, that's the bottom line. And getting this kind of honest feedback from, from four industry leaders is really, uh, rewarding and, and unique.

Joseph M. Schwab 17:47

Profitability isn't in tension with clinical mission. It's what makes the clinical mission sustainable. No margin, no mission. A company that can't generate revenue can't fund the next iteration of the device or the next clinical trial or the next generation of training for the next wave of adopters. The financial model is not the enemy of the clinical outcome. It's the mechanism that allows the clinical outcome to scale. Charlie DeCook has evaluated pitches from the other side of the table, and he describes what distinguishes the evaluators who provide the most useful feedback from those who don't. It comes down to a specific kind of experience.

Charlie DeCook 18:36

I think the best pitches that I've seen so far at Shark Tank include probably a tag team, I think you have to bring your CEO with you. You have to bring the people that are knowledgeable enough to to fight with those sharks because our sharks are getting better every year. They have been pitched so many different products and they've had the personal pain of having to take a product, you know, and actually sell it within their company.

Joseph M. Schwab 19:01

That phrase, personal pain, is precise. An evaluator who has never had to sell a product within a large organization doesn't fully understand what it costs to change a system's behavior. They know it from the outside. The person who has lived it knows it from the inside. They know which questions the procurement committees will ask. They know how long the credentialing process takes They know what happens when the clinical champion moves to a different hospital, and they bring all of that experience to the room in the form of questions that a founder who hasn't yet lived through commercialization can't fully anticipate. This is why a tag team pitch, one that pairs the clinical vision with the operational and commercial expertise to deliver it, is more than a presentation strategy. It's a demonstration that the company has already solved the most common gap that derails early-stage med tech companies, the gap between the inventor and the people who know how to take an invention to market. So here's our second answer. Clinical value, financial logic, and strategic interest intersect at the point where the founder can speak to all three in the same conversation without losing coherence. The clinical case earns credibility, the financial case earns attention, and the strategic case, showing how this device fits the direction the market is moving and the priorities of the people in the room, is what earns a yes. Getting all three right in 15 minutes requires preparation, and that preparation starts long before the pitch. It starts on the day the first clinical problem was identified and during every decision made since. Well, when a pitch holds up through the first two layers of evaluation, when the clinical case is solid and the financial logic is coherent, the scrutiny doesn't end, it intensifies. Because the last thing a serious investor or strategic evaluates is the thing that is hardest to verify and most important to trust: the story. Not the story of the device, the story of the company, where it's been, what it's learned, and whether the person telling it can be believed. Under that level of scrutiny, not all narratives survive, and the ones that do tend to share some specific characteristics. Which brings us to our third question: Which narratives gain traction under scrutiny and why? In the field of investor psychology, researchers have documented a consistent finding across multiple studies. Investment decisions are influenced by both analytical and narrative processing. Investors use quantitative data to justify decisions, but they use story to make them. The narrative that accompanies the data determines whether the data gets interpreted generously or skeptically. This matters in med tech for a specific reason. In a field where development timelines are long and regulatory outcomes are uncertain and market adoption is slow, almost every company has a story that includes setbacks and pivots and unanswered questions. The question isn't whether those things exist or are gonna happen. The question is how the founder narrates them. A narrative that papers over setbacks, that presents a smooth arc from insight to clearance with no acknowledgment of what failed along the way loses credibility the moment due diligence begins. Because due diligence finds everything. The FDA correspondence that showed the initial submission was rejected, or the clinical site that dropped out of the trial, the manufacturing partner that had to be replaced. These things are in the record. A narrative that anticipates those findings, that names the pivots before the diligence team discovers them and frames them as evidence of learning rather than evidence of failure is the kind of story that survives the room. Charles Lawrie has been raising capital while simultaneously running a company and continuing to practice as a surgeon He describes the specific challenge of projecting confidence in that environment and what that confidence actually requires from the inside.

Charles Lawrie 24:17

Projecting that confidence, I think, goes a very long way. Because you get to a certain point, you have some funding, you have some customers, and then all of a sudden it becomes this hamster wheel. You know, more customers and then more investors are involved.

Joseph M. Schwab 24:31

What Charles is describing is the compounding nature of credibility. Early traction, even modest traction, first customers, first clinical sites, first real world data changes the conversation in the room. It moves the evaluation from will this work to how far can this go? And that shift matters enormously because those two questions carry very different risk profiles and very different valuations. But the confidence that enables the shift isn't bravado, it's coherence. It's the alignment between the story being told and the evidence supporting it. When a founder says, "We've proven this at 10 sites, and the data shows consistent results," that is a confident statement that survives scrutiny because the evidence is there. When a founder says, "We believe this will work at scale," and the evidence base is thin, that's a confident statement that doesn't survive the first detailed questions. The research on due diligence in med tech is clear on what kills narrative at this stage. Disconnects between the pitch deck and the underlying documentation are the single most common reason deals stall or collapse during diligence. Not because the disconnect is always intentional. Often, it reflects a founder who genuinely believes a more optimistic version of the story than the data supports. The room finds those gaps, and when it does, the entire narrative comes under suspicion, including the parts that were accurate. Robert Cohen has been on the receiving end of hundreds of pitches over four decades and has seen that pattern from the evaluator side. His advice for what makes a narrative resilient under pressure comes from watching many that weren't.

Robert Cohen 26:39

stay true to your design. If you design a good product and you design it for good reasons, people will want it. Robert that's all you need to think about, let others that are smart. Let others people that know, finance and know marketing, sales, and know business plans. Let them lead you. You don't have to own everything. You don't have to be perfect. in Everything. You don't have to be the smartest person in the room. Be a good listener and stick to your competency and sticking to my competency are words to live by

Joseph M. Schwab 27:05

Stick to your competency. That is a piece of advice that sounds simple and is actually really hard because the pressure in the pitch room is toward expansion, toward claiming more territory, more capabilities, and maybe more certainty than actually exists The temptation is to say, yes, we have thought about that, rather than sometimes admitting the honest answer, which is, that's a gap we're still working to close. The founders whose narratives gain traction in the decision room are the ones who resist that pressure. They know what they know and what they don't. They claim the things they have proven and describe the things they have not yet proven as the work that remains. That kind of intellectual honesty doesn't weaken a narrative in the decision room. It strengthens it because it gives the investor or strategic something they almost never get, a founder they can trust to tell them when something is wrong, not just when something is right. And ultimately, that is what the decision room is looking for. Not a perfect story, a trustworthy one. So here's our third answer. The narratives that gain traction under scrutiny are the ones that are internally consistent, honest about what has not yet been proven, and grounded in evidence that survives review. The founders who earn support aren't the ones who present the most optimistic version of their story. They're the ones whose story holds up the same way under pressure as it did in the opening minutes. That consistency between the pitch and the data, between the claim and the evidence, between the confidence and the actual state of knowledge is the signal the room is looking for. So let's step back and review what we've learned. This was the first episode in this series where we stepped out of the founder's perspective, and what we found on the other side of the table isn't an adversary. It's a mirror. The decision room reflects back the quality of every choice the founder has made since the idea first sparked. In the first question, we learned that what drives decisions behind closed doors is the accuracy of the founder's model of their own situation, clarity about the problem and honesty about the path, and evidence that this person's judgment can be trusted under the kind of pressure that innovation always eventually applies. In the second question, we learn that clinical value, financial logic, and strategic interest don't align on their own. They have to be bridged explicitly and deliberately in the same conversation. A product that is clinically excellent but economically incomplete won't make it through the room. A product that generates returns but can't demonstrate patient benefit won't survive the scrutiny of the clinical experts either. The strongest case makes all three arguments and shows how they reinforce each other. And in the third question, we learn that the narratives that survive aren't the most optimistic; they're the most honest. Due diligence finds everything. Founders who acknowledge what they have not yet proven become trusted. Founders who paper over uncertainty are exposed. And trust, once broken in the decision room, isn't really recovered. And if there's one thing to carry forward from this episode, it's this: the decision room doesn't exist to stop innovation. It exists to test whether an innovation is ready to be carried further by people whose resources and reputations are now attached to it. The scrutiny isn't the obstacle, it's the proof. But there is a catch. Passing the test of the decision room isn't the end of the journey. It's simply the moment the stakes become permanent. In this series, we've seen how an idea is shaped and judged, but an idea is a weightless thing. A company at scale isn't. When adoption accelerates, the friction of the real world begins to grind against your assumptions. The hospital committees you ignored, the regulatory edge cases you didn't see, and the legal agreements you signed too quickly, they all come due at once. At this stage, maturity doesn't mean you've made it. It means you're finally large enough to break. In our next episode, we explore the second valley of innovation. We look at what happens when success moves faster than your systems can handle, and why the hardest part of the journey might not be the climb. It's staying upright once you reach the top. Because what happens when your idea finally works and then it starts to break?