Essay · Commercialization
Selling into interventional medicine means meeting different clinical worlds on their own terms · Juan Vegarra
Most people who come into medical devices from the outside make the same mistake I almost made. They start with the technology. They build a pitch around what the product does, how it works, and why it is better, and then they go looking for clinicians who will sit still long enough to hear it. It is a natural instinct, and it is almost always wrong.
The clinicians who decide whether a new tool lives or dies are not waiting to be impressed by technology. They are running a demanding day, with patients in front of them and a workflow they have refined over years. The question that actually determines adoption is not whether your product is clever. It is whether it fits the job they already have and makes that job better, on their terms. Go-to-market in this world does not begin with the product. It begins in the procedure room.
What makes interventional medicine particularly humbling is that there is no single procedure room. The same company can be selling into several completely different clinical worlds, each with its own rhythm, its own economics, and its own definition of what better even means. Treating them as one market is a fast way to fail in all of them. This is not an argument against great technology. Technology that does not work will not be saved by any amount of empathy. The point is narrower and more useful: in this field the technology is the price of admission, not the reason for adoption. Two companies can arrive with comparable products, and the one that wins is almost always the one that understood the room better.
The interventional cath lab is one of the most choreographed environments in medicine. Cases are scheduled tightly, the team moves through a sequence it has performed thousands of times, and time is the scarce resource that governs everything. An interventional cardiologist in a busy lab is not looking for more information to weigh. They are looking to move through each case safely and efficiently and get to the next patient.
In that environment the deciding question for any new tool is brutally simple. Does it fit the flow, or does it break it? A technology that adds steps, adds time, or forces the team to stop and think in the middle of a case is fighting the single most powerful force in the room, which is rhythm. Add to that the economics of the ambulatory setting, where supplies can be half the budget of a case and margins are thin, and the bar is even higher.
You do not win that room by doing more. You win by fitting the flow and respecting the math, by giving the team something useful at the exact moment they would already want it, without asking them to reorganize the day or blow the budget. The best thing anyone can say about a new tool in that lab is that they stopped noticing it was new.
Trust in that room is also earned in person, case by case. A high-throughput lab does not adopt on the strength of a brochure. It adopts when a respected operator has used the tool enough to vouch for it under real conditions, and when the first cases went smoothly enough that the team stopped bracing for disruption. That is why proctoring, peer proof, and a flawless early experience matter more than any feature list. The reference that moves this room is another operator like them saying it did not slow them down.
The second world looks different. A great deal of peripheral work happens in office-based labs and ambulatory centers, where the physician who uses the device often also carries the capital and the risk of the practice itself. The economics are personal in a way they are not inside a large hospital, and a tool is judged not only on whether it works but on whether it makes the practice stronger.
But peripheral care carries something heavier than economics, and any honest account of the room has to name it. More than 70 percent of major leg amputations happen with no prior attempt to save the limb, and the odds of which path a patient is offered vary sharply by who and where they are. The more definitive, often better-reimbursed option can happen before anyone tries the harder, limb-saving one. Who gets offered which path is not only a clinical question. It is an economic and structural one.
Selling into this world, then, is not just about fitting a practice's economics. It is about whether you make the better path easier and more economical to choose, rather than building a more elegant version of a procedure the system already reaches for too readily. The companies that earn real trust here are the ones whose economics push in the same direction as the better decision.
That alignment has to show up in the evidence and the economics, not just the intention. A company that wants the better path chosen has to make it defensible to the committee that pays and easy for the practice that performs it, with data that holds up and a payment story that does not punish the physician for doing the harder, better thing. Good intentions that leave the better path more expensive or more burdensome will lose to the easier option every time.
The third world is different again, and the thing that defines it is acuity. Pulmonary and thoracic work happens in anatomy that is unforgiving and often hard to reach, where the margin for error is thin and a complication can escalate quickly. The dominant fact in that room is not throughput and it is not practice economics. It is what happens when something goes wrong.
There is a sobering pattern in the data that captures why this matters. Across many procedures, high-volume and low-volume centers have remarkably similar complication rates. What differs is rescue. At the lowest-volume centers, patients are far more likely to die once a serious complication occurs, not because the complication was more likely, but because the room was less able to recover from it. The difference between a good outcome and a tragic one is often not the procedure. It is the room it happened in, and who was there when the situation turned.
That changes what a clinician in this world is actually buying. What they most want from a new tool is not speed and it is not margin. It is control, the sense that the tool makes a hard situation safer and more recoverable rather than adding one more unfamiliar variable to a room where rescue is everything. Claims here have to be careful and well supported, because a tool that promises control and fails to deliver it does not merely lose a sale. It loses trust in a field where trust is the entire game.
There is a hard design lesson buried in the rescue data. Your product will not only be used in the best centers with the deepest benches. It will be used in the average room, on an ordinary day, by a team that may see fewer of these cases. Designing for the best room flatters the engineering and misleads the business. Designing for the average room, where the margin for error is thinnest and rescue is least certain, is what actually protects patients and earns durable adoption.
Three rooms, three different definitions of better. The cath lab rewards rhythm. The office-based lab rewards economics and the courage to make the right path the easy one. The high-acuity suite rewards control and the ability to recover when things go wrong. A tool that is perfect for one of these worlds can be actively wrong for another, and a company that does not see the difference will misread its own results.
This is also why a single, centrally written message rarely survives contact with all three rooms. The company that insists on one master pitch, applied uniformly because it is cleaner to manage, is optimizing for its own internal tidiness rather than for the buyer. The discipline is to hold the underlying philosophy constant, meet the clinician inside their day, and let the specific story flex to the room you are standing in.
This is an organizational discipline as much as a messaging one. It requires a commercial team trusted to adapt, trained deeply enough in each world to know what better means there, and a leadership that resists the urge to enforce one tidy story for the sake of the dashboard. The companies that scale across these worlds are the ones that built that flexibility on purpose, rather than discovering its absence one stalled launch at a time.
There is one more layer that outsiders consistently underestimate, which is that in much of this world the clinician who wants your tool is not the only person who has to say yes. In a hospital, a new device typically has to pass through a value analysis process, where a committee weighs the clinical case against the cost and the contracts already in place. An enthusiastic champion can open the door, but the institution decides whether you actually come through it.
This means a complete go-to-market has to serve two audiences that judge you by different standards. The clinician asks whether the tool makes them better at the work. The institution asks whether it is worth the cost, whether it displaces something already under contract, and whether the evidence will withstand scrutiny. A company that wins the clinician and ignores the institution stalls in committee. A company that speaks only to the institution and never earns a clinical champion has no one inside the room arguing for it. You need both, and they are not persuaded by the same things.
The institution's questions are also where contracts and incumbency quietly decide outcomes. A new device often has to displace something already under agreement, with switching costs and relationships attached, and the committee will ask whether the evidence justifies the disruption. This is why a clinical champion, while necessary, is rarely sufficient. The teams that get through learn to arm their champion with exactly what the institution needs in order to say yes.
The instinct to lead with the product is understandable, because the product is the thing you built and the thing you are proud of. But the clinician does not experience your product as a product. They experience it as something that either helps or hinders the work they were already doing when you walked in.
The discipline, in every one of these rooms, is to walk in already understanding that work. Go-to-market in interventional medicine does not begin with the pitch. It begins in the procedure room, on the clinician's terms, in the language of the day they are actually having. When you look at a market you are trying to enter, how well do you really understand the day of the person who has to say yes?
Juan Vegarra is the author of An Outsider's Playbook (forthcoming). The views here are his own. More from the Notebook · Continue the conversation