The $3B Patient Recruitment Crisis: Digital Solutions | Sandra Shpilberg (2/4)

Intro - 00:00:06: Welcome to the Biotech Startups Podcast by Excedr. Join us as we speak with first-time founders, serial entrepreneurs, and experienced investors about the challenges and triumphs of running a biotech startup from pre-seed to IPO with your host, Jon Chee. In our last episode, Sandra reflected on her early life in Uruguay, her family's escape from the Holocaust, and how growing up in a small Jewish immigrant community shaped her worldview. If you missed it, check out part one. In part two, Sandra talks about her time at BioMarin, how she led commercial efforts for rare disease therapies, learned to work cross-functionally, and saw firsthand the impact of patient-centered drug development. She also shares what drew her to startup life, why she left big pharma, and the spark that led her to start building companies of her own.

Jon Chee - 00:01:11: And now you're going to a much smaller organization where you're wearing all the hats. Very different, kind of polar opposites. Talk about the early days at BioMarin.

Sandra Shpilberg - 00:01:25: When I joined BioMarin, the company was about 250 employees. When I left, it was about 4,000. When I joined, the company's stock was at $4. When I left, the company's stock was at $120. When I joined, they had one product they were marketing, which they had acquired. When I left, they had three products that they were marketing and a pipeline that would be the envy of any biotech company—a rich, thick pipeline. So, basically, BioMarin was a rocket ship, and I joined pretty early, is the bottom line.

Sandra Shpilberg - 00:02:08: I had two eras in BioMarin. The first era is when I was in the marketing department. I was leading the marketing department to execute the first few launches for BioMarin. BioMarin had never launched a drug before on their own, and now we were going to go ahead and execute this. These launches were in rare diseases—so diseases that generally affected 15,000 people in the US, sometimes 1,000 people in the US, and so they were very different than anything else that I had experienced. So it was complete entrepreneurship, complete innovation, pioneering, coming up with new ideas. In a way, it was a really good job for me because it was a little bit of, "Well, we could look at big pharma and see what they're doing, but it doesn't necessarily mean that we need to do it. We need to think critically and analyze the situation and then decide to create this playbook for this rare disease company." And now there are a lot of rare disease manufacturers, but at that point, there weren't. There were really only five or six companies operating in the rare disease market.

Sandra Shpilberg - 00:03:17: So this job was great for me. It was completely an opportunity to innovate, to feel like a pioneer, to work on drugs that were first to market. The drugs that BioMarin was working on, there was no treatment, and we were going from no treatment to a treatment. The other thing that was really important in that job is we were very close to the patients. At Johnson & Johnson, we would see patients, but generally, they would come to this national sales meeting, be fully prepped, and do a speech telling us how important Remicade was to them. This is not how we saw them at BioMarin. At BioMarin, they came every time we had a get-together for employees, and they were part of the BioMarin family to the extent that I am still friends on Facebook with some of our patients—the parents of the patients. I was invited to the high school graduation of a patient who thought she wasn't going to live to reach her high school graduation. Due to the fact that she has been on BioMarin's drug, Naglazyme, she is still alive. She's about 36 years old right now. So what we were doing at BioMarin was so meaningful, and every day you could wake up and see the value that we were delivering to people's lives—literally extending the lives of these very sick patients with rare genetic diseases.

Sandra Shpilberg - 00:04:36: That was the first part with Naglazyme. The second part was Kuvan. Those patients were a little bit more controlled. They had slightly better outcomes, but we were still very, very close to the patients. And some of the work that was happening, let's say, in PKU was really foundational to the PKU community. So that was one of the important things of seeing how a biopharma company that is coming into a rare disease has the real opportunity to partner with those patients and create not just the drug, but create structures, education, and advocacy that is going to benefit all the patients, whether they are on the treatment or not. And that's a lot of what we did in that market in PKU. We basically set up the structure for a national PKU alliance, for advocacy for the treatment, as well as for education, like clearing up a lot of the messages that were wrong in that particular disease area. So that was the first four years.

Jon Chee - 00:05:35: Wow.

Sandra Shpilberg - 00:05:36: An incredible experience.

Jon Chee - 00:05:38: Wow. They put you in the deep end—a wonderful deep end, but it's like, "Here you go."

Sandra Shpilberg - 00:05:44: Deep end of the pool. But, you know, I mean, looking back, I recommend it. I think it was good. And, you know, during this time, I also thought, "Oh, you know what? It's probably a good time to have a second child because my first child is three already." And we moved, so we were waiting. We weren't gonna have a baby when we were moving. So my daughter was born a week before Kuvan, the second product of BioMarin, launched. So I had two babies launching at pretty much the same time.

Jon Chee - 00:06:12: There we go. Man, double deep ends. And so the next era of BioMarin, the next four to five years, how did things change for you in that era?

Sandra Shpilberg - 00:06:24: Yeah. Significantly, actually. So what happened is I launched Kuvan, and at that point, I was part of what's called the core team, which is the program management team that is developing the product, moving the product forward even past approval to think about extensions and all those things. Being part of that team, I had access to the core team lead. At that point, it was Dan Oppenheimer who came to me and said, "You know, you've done the launch. We are now working on a second product for PKU, PEG-PAL, which is now called Palynziq. And I am thinking it would be great, since you already launched one product, that we take you and put you in a position where you lead the cross-functional core team for moving this product that is currently in Phase II, and we need to get it to Phase III and approval." So this would be a very different job. You're bringing in all your commercial know-how of knowing where the end goal is, where we're trying to get to. But the product is in Phase II, and your role is now to manage this cross-functional team—manufacturing, regulatory, clinical operations, clinical, and commercial—to oversee the entire strategy and move the product forward.

Sandra Shpilberg - 00:07:44: So he asked me if I was interested in the job, and at that point, I was like, "Yeah. I'm totally interested in the job." Number one, it's so much more strategic than what I've been doing. I was doing the blocking and tackling.

Jon Chee - 00:07:53: Yeah.

Sandra Shpilberg - 00:07:54: The rubber is meeting the road, and the product has to get to the patient. The website has to get to the patient, and the patient has to be able to register. So it's all very—there was strategy, but it was also the tactical implementation. So I liked that role, one, because it's more strategic, and two, because it was going to allow me the opportunity to see the entire development process and then manage and get familiar with the entire biopharma operation. So they worked it out with the bosses because, basically, it's like, "Hey. Can I steal your person?"

Jon Chee - 00:08:26: Yeah. Yeah. Hope you don't mind.

Sandra Shpilberg - 00:08:29: "Hope you don't mind."

Jon Chee - 00:08:29: "We're gonna take a rock star and just put her on someone else's team. Hope you're okay with that."

Sandra Shpilberg - 00:08:34: "We'll just steal her. Is that okay?" Yeah. So, anyway, they worked it out, and I moved over to program management to lead the core team for Palynziq. I got the product in Phase II, and that was a very strategic role where basically the first milestone we're trying to hit is an end-of-Phase II meeting with the FDA. Right? That's what we need to get to. And so for this end-of-Phase II meeting with the FDA, we need the clinical trial done. We need to have manufacturing pretty stable. We need to have regulatory filings all in shape. And so that was the first milestone. And then the second milestone was, "Okay. Now after the end of Phase II, we have to get ready to start the Phase III and then complete the Phase III." So I was at BioMarin during those four years where all of this was being done.

Sandra Shpilberg - 00:09:27: This product was particularly challenging and new and pioneering, not only for BioMarin but for the entire industry. It was a bacterial enzyme that was being delivered as an injectable medication. So things that hadn't been done before.

Jon Chee - 00:09:44: There wasn't precedent. Right?

Sandra Shpilberg - 00:09:45: Yeah. There wasn't a lot of precedent for a lot of these things. BioMarin had never launched an injectable medication. We had an infusible, and we had a tablet. So there were a lot of new components here to work with. And from the perspective of me growing as a professional, this job just completely opened my brain. Like, now I could talk about clinical trials. I could talk about manufacturing of these drugs. I could talk about regulatory filings and commercial, which I knew very intimately. So it was an excellent move for me, and it was also an excellent move for BioMarin because we did tackle the things that came up. I always called that job a bit like playing whack-a-mole. It's like, "Okay. Month one, manufacturing is not working. What now?"

Jon Chee - 00:10:35: Yeah.

Sandra Shpilberg - 00:10:36: "Month two, clinical trial enrollment is not happening. Okay. Let's do that."

Jon Chee - 00:10:41: Yeah.

Sandra Shpilberg - 00:10:42: "Month three, they delayed our meeting..." Every month, there was something happening, but we got through it, had a great team, had a couple of great people working under me as well. So I got the product all the way through to almost the end of the Phase III, and then another phone call came.

Jon Chee - 00:11:04: There's a theme here.

Sandra Shpilberg - 00:11:06: Yes.

Jon Chee - 00:11:07: Interesting. And when you look back on the BioMarin experience, what did you find most exciting about your roles there? And what was the hardest part? It couldn't have been all puppies and rainbows.

Sandra Shpilberg - 00:11:20: No. It wasn't. It was very hard work. It was actually quite intense and somewhat stressful. So I think the best part for me, for somebody with an entrepreneurial spirit, is that we were doing new things. We were innovating. We were creating things from scratch. We were basically almost dictating and testing the playbook for launching rare disease drugs, for developing rare disease drugs at scale, and being able to do it in a repeatable way. So that was what was really exciting and all the things that come with that—that we're very open and willing to try new approaches. There's a lot of variety of experiences, pilot programs we're comparing. So we had a high degree of innovation and pioneering and trial and entrepreneurship. So that was what was good.

Sandra Shpilberg - 00:12:12: What was challenging is that it was very intense. It wasn't a cushy job. There were always things going on. The job required a tremendous amount of energy. There was also a lot of travel involved with the job to go to congresses. And at this point, I had either one or two young children. So the job was definitely challenging. There was also the organization to work through, and the degree to which the entire organization was aligned to try some of the things that we wanted to try. And then there was also managing expectations. I remember early on in the launch of Kuvan, Kuvan had very high expectations. Everybody thought, "Oh, everybody should take this. This is the best thing that ever happened to PKU." And you know what? It turned out that patients had a lot of inertia. They had misconceptions about how their disease worked. They had misconceptions about how the diet, which was the other thing that you could do to control PKU, was effective for them. And so it took a while to really begin to educate patients and providers to say there is an opportunity for this product. It can help this type of patient, and it's not gonna help every patient. That was one of the most challenging things we had to do at BioMarin—to navigate that line of saying, "It can help your patient, but it's not gonna help every patient." And you have the opportunity to try it. So we set up a trial program for the product that was very innovative so patients could try it for free and see if it worked. And then if it worked, if they were a responder to the product, then they would stay on. And then if they weren't, they would come off.

Sandra Shpilberg - 00:13:51: So the product I was launching was challenging. The market was challenging and had a tremendous amount of inertia and miseducation. The organization of BioMarin was growing rapidly, so people were being added and, you know, not everybody was able to work with each other. So I do remember lots of movement, lots of changes. And, you know, the other side of trying to do innovative things is that they're innovative things that haven't been done before. So many times, I had to go to compliance and tell them, "Oh, I know that there are no websites out there requesting patient information, but that's what we have to do." And so I actually appear in the book that was written about BioMarin, basically saying this quote, which is, "I don't wanna come here with an idea for compliance and for you to tell me no. I want you to tell me how. Like, how do we do this? This is what we need to do. We need to get patients into a patient database. What do we need to do to make that happen?" Because a flat "no" is not going to work for the situation that we're in right now. So that's the other side—that there was a lot of maneuvering and figuring it out that had to happen, which is not always pleasant.

Jon Chee - 00:15:00: Absolutely. I can imagine those are hard conversations.

Sandra Shpilberg - 00:15:03: Yes.

Jon Chee - 00:15:03: And holistically, looking back on BioMarin, what are some key lessons or takeaways that you carry with you to this day that derived from that BioMarin experience?

Sandra Shpilberg - 00:15:13: The first one is that we are in business for the patient. And the closer we can be to that patient in understanding them, their family, their life, their concerns, what they know about their disease, what they don't know about their disease, the better we all win. For sure, that is number one. Number two, the people in the organization really matter. People make or break a launch. A launch is this big thing, but it's really about the people that are showing up. And if you have a really committed product manager that's like, "She wants to get this done," it's gonna get done. If you have a really committed sales director, and he's going to get everybody motivated to go the extra mile, it's gonna get done. So the people really matter a lot. At the end of the day, whatever strategies we're talking about are all implemented with people. And so the people we select for these roles, how we retain them, how we tell them they're doing a good job, how we help them grow in their roles is incredibly important.

Sandra Shpilberg - 00:16:19: And then I think the other thing with BioMarin is to welcome growth. It was an organization that never sat still. It was always looking for, "What else can we be adding to this pipeline? What else could we be doing?" And I think in business, that's a really good mindset to have. We do business within a dynamic market that is completely changing, and the posture is awake and engaged with the market. So that we can understand what's happening, what is changing. We cannot be asleep at the wheel. We cannot be resting on our laurels. Business is an active posture of, "We are in the market. We're present in it. We are listening. We're understanding. We're adjusting our behavior, and we're constantly trying to improve what we're doing and how we're doing it."

Jon Chee - 00:17:04: Absolutely. I couldn't agree more. And I think, especially when you get some early wins, you can kind of start to feel that complacency—it's a bit too strong in this case—but you're just like, "Great. We can ride this one out." And the sense of urgency, you can feel it starting to drop, but it sounds like BioMarin just did not stop the urgency. And I can imagine when you're interfacing with patients, the urgency is very present. "No. This is just the beginning. We should be doing more." And I absolutely agree business is constantly going through growth spurts. And then when you stop growing is when you're dead.

Sandra Shpilberg - 00:17:43: Exactly.

Jon Chee - 00:17:44: So it's incredibly important to keep that in mind when you start to feel the sense of urgency slowing down. So now you got that telephone call. BioMarin sounded like an awesome gig. When did you know it was time to leave, and how did that conversation go?

Sandra Shpilberg - 00:18:01: You know, I think I could have stayed at BioMarin for the next ten years. I don't think I would have left because I liked my job. I was engaged in it, and things were going well. But I did get a phone call. And this time, the phone call was about a smaller company. So, you know, my ears perked up because one of the things I noticed was I'm going smaller and smaller and smaller. Johnson & Johnson, BioMarin, and then this smaller company calls, Nora Therapeutics. They had done some venture backing, raised something like $28 million, and they had a compound that they were testing in women's health in IVF failure and recurrent miscarriage. And here, I was going to get to be the vice president. So it was going to be an increase in title because at BioMarin, I was an executive director. And the company was in Palo Alto, and I was living in Marin, very close to BioMarin.

Sandra Shpilberg - 00:18:56: As a working mother, I always liked to live very close to my work area because then it meant that if the kids needed to be picked up from school, I was five minutes away. Or if somebody got sick, I was five minutes away. And, you know, of course, I had a lot of caregiving support during that time, but it made me feel better to be very close to work. And so this job was in Palo Alto. So, we had to think at that point as a family whether or not we wanted to move to Palo Alto, and we really did. My son, at that time, was a chess competitor, a chess champion, and all his tournaments were in Santa Clara.

Jon Chee - 00:19:31: Oh.

Sandra Shpilberg - 00:19:31: That's where they were. And my daughter was younger, so her activities were just beginning to be nascent, and she hadn't really even started first grade yet.

Jon Chee - 00:19:44: Yep.

Sandra Shpilberg - 00:19:45: So when this call came, it wasn't just about moving jobs. It was basically about finding the next life that I thought would be really good for our children and giving them an opportunity to be raised in a place that would be vibrant and interesting for them. And so the Palo Alto component was very important in the job. And, you know, it took another leap, and then I basically said yes to the job, which allowed us to move to Palo Alto. My kids practically grew up in Palo Alto, which is one of the best places to grow up in. It is not what the media portrays. My kids went to public schools in Palo Alto. They rode their bikes there along with dozens of other kids riding their bikes together, a huge sense of community, and almost like this idyllic old-time feeling of everyone in the community taking care of the kids that are going on their bikes to school. So I'm actually really glad from a family perspective that we did that, and we moved to Palo Alto. Of course, housing was always very complicated, but we managed it.

Sandra Shpilberg - 00:20:45: So the kids grew up in Palo Alto, and I got this job. I had this job at Nora Therapeutics. I was VP of Strategic Marketing and Commercial Operations. I'm joining the company in Phase II of this compound that has two clinical trials. And basically, I'm the first commercial person. There are eight people in the company. We pretty much all sit in one room together all day long, and the whole goal of the company is to finish these Phase II studies and ideally get enough positive data to then go do an IPO to then do the Phase III. So the proposition was exciting. It was very exciting because it was like, "There's an opportunity to start at the bottom of this and also take it somewhere and start even earlier than I did at BioMarin." So I came into this job very quickly after they unblinded the results of the first study in IVF failure, and the drug failed.

Jon Chee - 00:21:55: Oh my god.

Sandra Shpilberg - 00:21:56: And people were pretty upset, and I'm in the job for a month when this happens. I'm like, "Okay. That's not good."

Jon Chee - 00:22:01: Yeah. "I just relocated my whole family month one. Oh goodness."

Sandra Shpilberg - 00:22:09: It has to be a leap of faith. But, basically, it's like, "Okay. That's not good that the drug failed." And we're all thinking like, "Well, I wonder what this means for the second study, the second indication for recurrent miscarriage." And so very quickly, we shift the whole company to be like, "Okay. Well, IVF failure is done. The drug failed for IVF failure, and now we have to refocus everything to recurrent miscarriage. Let's go there. Let's get the study done." The study was having difficulty enrolling, yet the patients for this study, they were all online. Women generally, women that are suffering from any kind of infertility complication, turn online to talk to other women that are suffering from the same infertility complication. So they were all online, and yet the study was struggling. And I'm sitting here being like, "Commercial operations is the one responsible for this, but they're putting a lot of marketing things together to help, so I can help." So I basically start putting together for them what eventually becomes a patient-finding, a patient activation campaign to let these women know that there's a clinical trial that they can join if they had this recurrent miscarriage happening to them.

Sandra Shpilberg - 00:23:25: And so we patch this thing up. And what appears to me is, I can't go and hire a company to do this. There's no company that can do Facebook ads for me, that can do Google ads for me, and tell these women in these specifics—like, "Why doesn't this exist?" So anyway, we patch it up. I patch up this and that, and we get into a system where we have some leads coming in, some patients that are self-referring, or sending them into the site, and eventually, the study enrolls. And then, maybe about a year into my stay there, they unblind the study, and there is no significant effect of this medicine. So the drug failed.

Jon Chee - 00:24:07: Oh, boy. That's brutal.

Sandra Shpilberg - 00:24:10: Yes. And so at that point, basically, the CEO is talking to us saying, "We had one compound. We had two indications. The drug failed in both. That's it. This is the end of the road for this company. We plan to disband the company, and we will give you each a severance package." So for the first time in my life, I got a severance package.

Jon Chee - 00:24:34: Wow. Yeah. And also, this is right off the back of BioMarin as well, which was just homers. And so it might have been—I can't imagine how you were feeling. It's a stark contrast.

Sandra Shpilberg - 00:24:50: Very stark contrast. Because BioMarin, by then, was a stable company. I could count that it wasn't really gonna go down. I could count that I was getting paid my salary and my benefits and my stock options. And then I trade all of that to take this risk, which ends up from that perspective not panning out. However, the risk does pan out. So let me tell you how it all makes sense.

Jon Chee - 00:25:15: Yeah. Yeah. Tell me.

Sandra Shpilberg - 00:25:17: At Nora Therapeutics, I discovered a huge hole in the market. I discovered that companies like Nora Therapeutics were not able to find a single end-to-end provider of online patient enrollment. And I knew that this was a hole because I went to try to find it, and I couldn't find companies that were doing it either end-to-end enough or well enough. And so at Nora, what I gain from that experience is the understanding that there is a huge problem in this market that affects pretty much every single biopharma company and that is currently not being solved properly. And then at the same time, this emerging technology—Facebook advertising, Google, Instagram, TikTok wasn't even there, but it's gonna keep going—where there's an opportunity to reach patients through digital channels that we were, at that point, not taking advantage of. And this is now ten years ago, so it's a long time ago. Things have obviously changed.

Sandra Shpilberg - 00:26:17: And so when I leave Nora Therapeutics, I say, "I'm not going to go get another job. I'm not. I have a few months of severance where the company is paying me, where I don't have to worry about benefits or my salary. I'm gonna go and I'm gonna start a company. And I'm gonna start a company that is going to do what I just discovered that I couldn't find a good company to do for Nora Therapeutics. I'm gonna go set that up. I'm gonna set it up the way I would wanna buy it. And then see if anybody wants it."

Jon Chee - 00:26:56: Very cool.

Sandra Shpilberg - 00:26:57: And so that's the thing that at first sight looks like I'm going from BioMarin where I have an excellent job, top-of-the-line job in everything, and I take this risk to go to a startup whose product ends up failing a year later. But that year was very important to me because in that year, I do two things. One, I take off my golden handcuffs. I say, "I don't need to be in this golden handcuffs situation. I can be not in that." I take off my golden handcuffs, and then two, I discover that there is a problem that I could set up a company to fix. And so that was actually invaluable.

Jon Chee - 00:27:39: Yep. I love that because I'm a firm believer that every experience is accretive in some way. Just accumulating these experiences, it's kind of like putting yourself out there. You've gotta just put yourself out there, and you'll discover. And I sometimes think the BioMarin hitting home runs situation, like, going to a smaller company where there are some setbacks, opens your eyes to things that BioMarin would have probably never seen because you just have all these successes. For me, when I started Excedr, I did rotations at Berkeley in laboratories—some well-funded, not so well-funded. If I spent all my time in a well-funded laboratory, Excedr probably wouldn't exist because getting equipment was not a problem. I remember people would just buy $40,000 of consumables and forget about them in the fridge.

Sandra Shpilberg - 00:28:31: Yes.

Jon Chee - 00:28:31: "And if you want a piece of equipment, let's get three of them."

Sandra Shpilberg - 00:28:34: Yes.

Jon Chee - 00:28:34: And if I lived in that environment, I would assume that's just normal. But I spent most of my time in a less well-funded lab only to figure out, kind of what you said, that pain point. And then I was like, "Is this what life's like for most labs?" Because most labs are not incredibly well-funded and flushed with cash. And I started to have these conversations with other labs, and they're like, "Oh, yeah. Most of us can't afford equipment." And I was like, "Okay. It's time for me to start my company." So I can imagine myself in your position at that time. You're just like, "This is a prevalent issue," but you probably would have not felt it as viscerally unless you were at Nora.

Sandra Shpilberg - 00:29:12: Exactly. So at BioMarin, I always ask myself that question. Why didn't I have the idea for CICA Health, the company that I found after Nora? Why didn't I have that idea at BioMarin? And the reason why I didn't have the idea at BioMarin is that even though I was managing that clinical trial, I was still pretty detached from it. I wasn't in this room of eight people where we were figuring out exactly how to make this happen. I had a director of clinical operations, so she had a manager of clinical operations, and he had another analyst of clinical operations. And there were lots of people, and they were dealing with it. I didn't have as much visibility into the problem, and I also didn't have as much visibility into what they were doing to solve the problem.

Jon Chee - 00:29:57: Yep.

Sandra Shpilberg - 00:29:58: Right? By the time it came to me, it was all very strategic, and it was either, "It's working, it's not working." "If it's not working, we're figuring it out, and this is what we're doing. We'll give you another report." I didn't have the intimacy that I needed to have to know the problem. So I was never gonna come up with this idea at BioMarin. I needed to be in a place where it was eight people and where we were around the conference room, and it's like, "The trial enrollment stopped, and we have to do something about it now." And it becomes much more of, "Oh, now I'm deep in. We're figuring out how to put together a website for this particular trial, how to take in leads, how to create ads." I was never gonna get to do that at BioMarin because I was already too strategic for it.

Jon Chee - 00:30:40: Yeah. And there are probably eight people, ten people, however many people that subdivided that problem, and then it felt like it wasn't a problem. Because you have the ability—I think that's something about venture creation and startup creation. This is a Jon philosophy. I don't want to say this is how it is. It's just an observation of mine that when you're incredibly well-funded, you can kinda throw money at problems and assume it's not a problem.

Sandra Shpilberg - 00:31:11: Yes.

Jon Chee - 00:31:11: But when you're not so well-funded and you have to—exactly as you said, there are eight of you, and you're like, "We can't just throw people at this because there are only eight of us"—you have to figure out an efficient way to do this, and you're just like, "There is no efficient way to do this. It doesn't exist." And that's where the opportunity is. And that's why I think sometimes golden handcuffs, being overcapitalized can also be a form of that where you lose that intimacy of peeling back the layers all the way and noticing that there's this latent problem. You could just assume that there are no problems because you're like, "I'm just gonna throw $100,000 at that thing, and it'll solve itself. We can staff this thing to the moon, and then it'll be fine." Anyways, that's just me waxing a little bit philosophic.

Sandra Shpilberg - 00:31:56: And, you know, I think maybe also the other thing is that when I think about BioMarin, they had a lot more experience enrolling clinical trials than Nora Therapeutics did. So it could also be that really for BioMarin, this was a minor problem. Maybe at some points, the trial slowed down. It didn't enroll as well, but it wasn't a massive problem. Well, at Nora, this was a massive problem that was directly in the way of getting to the milestone for this company. And so I think that's also the difference—that I had to be at this role where this was the massive problem. This was the boulder that we had to move out of the way in order for me to figure out that, yes, I had been able to patch something up, but that what I really wanted to buy as a buyer didn't exist at that point. That instead, I could turn around and go and build it.

Outro - 00:32:46: That's all for this episode of the Biotech Startups Podcast featuring Sandra Shpilberg. Join us next time for part three of our four-part series where Sandra shares how she went from laid-off biotech exec to first-time founder, launching CICA Health from her living room and landing her first customer on LinkedIn. She'll also talk about what it took to build a profitable bootstrapped business in clinical trial recruitment, why she focused on patient need over hype, and how she approached the decision to sell. If you're enjoying the series, be sure to subscribe, leave a review, and share it with a friend. Thanks for listening. The Biotech Startups Podcast is produced by Excedr. Don't want to miss an episode? Search for the Biotech Startups Podcast wherever you get your podcasts and click subscribe. Excedr provides research labs with equipment leases on founder-friendly terms to support paths to exceptional outcomes. To learn more, visit our website, www.excedr.com. On behalf of the team here at Excedr, thanks for listening. The Biotech Startups Podcast provides general insights into the life science sector through the experiences of its guests. The use of information on this podcast or materials linked from the podcast is at the user's own risk. The views expressed by the participants are their own and are not the views of Excedr or its sponsors. No reference to any product, service, or company in the podcast is an endorsement by Excedr or its guests.