Giant Robots Smashing Into Other Giant Robots

511: Tele911: Pioneering Remote Emergency Care with Dr. Ramon Lizardo

February 8th, 2024

Victoria Guido hosts Dr. Ramon Lizardo, CEO of Tele911, to discuss his company's innovative approach to emergency room diversion. Dr. Lizardo shares his journey from being a physician frustrated with the inefficiencies in emergency care to leveraging technology for better healthcare delivery. Tele911 is a service that transforms how emergency responses are handled. Rather than transporting patients to hospitals for non-critical care, Tele911 facilitates on-site treatments through paramedics equipped with iPads, allowing doctors to provide remote consultations, streamlining emergency services, and reducing unnecessary hospital visits and costs.

Dr. Lizardo's motivation for founding Tele911 was driven by personal experiences and the desire to improve emergency healthcare delivery. He recounts the challenges of pioneering in digital health, particularly the initial skepticism from investors and potential users about remote medical services. The COVID-19 pandemic became a turning point, accelerating acceptance and demand for Tele911's services, and Dr. Lizardo discusses the challenges of scaling the service, maintaining data privacy, and the importance of a values-driven approach to business.

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VICTORIA:  This is the Giant Robots Smashing Into Other Giant Robots Podcast, where we explore the design, development, and business of great products. I'm your host, Victoria Guido. And with me today is Dr. Ramon Lizardo, CEO of Tele911, the leader in emergency room diversion. Dr. Lizardo, thank you for joining me.

DR. LIZARDO: Hey, Victoria. Good to connect with you once again. How are you?

VICTORIA: I'm good. It's raining in San Diego, so, unlike the song, it does happen sometimes in Southern California.

DR. LIZARDO: [laughs] But I love San Diego, by the way. It's one of those places where I feel like you have literally the perfect weather and perfect access to food. I'm a fan of Mexican food. And you can literally get the best Mexican food from, like, all of the trucks in San Diego. I truly believe that.

VICTORIA: That's true. The only better place to get Mexican food in San Diego is just to go to Mexico. You --

DR. LIZARDO: There you go [laughter].

VICTORIA: Yeah. I actually went to a startup event that was in Tijuana on a Tuesday night and just walked over the border and walked back, and it was great.

DR. LIZARDO: That is awesome.

VICTORIA: [laughs]

DR. LIZARDO: You know, there's a lot of expats living there now. It's really interesting, in Baja, California.

VICTORIA: Yeah, there's some back and forth there. And yeah, so just give me a little bit about your background and a little bit more about Tele911.

DR. LIZARDO: I'm a physician by training, but I've been in tech for about 15 years now. Tele911 is basically the child of a parent that was really frustrated with their specialty. So, I signed up for emergency medicine, and I realized a lot of what was happening was primary care. That led me to pursue a career in consulting. I worked at one of the Big Fours, interned at McKinsey, worked at Deloitte. Then, I started or joined a series of other startups that were very successful.

About three exits in, I said, hey, remember that idea that actually got me out? Being frustrated in ER because a lot of these patients didn't need to go to the hospital but were there. Well, this is how this comes about. Tele911 is basically the product of a lot of frustration, but a lot of innovation. And now we're pretty much reshaping history. In California, Texas, or Florida, when a patient calls 911 now, an ambulance shows up, but instead of being taken to the hospital, they're actually seen at home in something called treatment in place. We're the doctor on the iPad of the paramedic.

VICTORIA: So, thank you. That's a great interest. So, you had this background in consulting, and you had this experience as a physician, and then you decided to solve this really big problem with the cost around emergency rooms. So, before we dive into more around Tele911 and what you're doing with it, I thought we could warm up a little bit by just telling me, what gets you up in the morning?

DR. LIZARDO: [laughs] What gets me up in the morning? Well, I'm blessed because I have a two and a six-year-old. So [laughs], the truth is they're the ones that get me up. They usually wake up way before I do. So, if you come to this house about 5:15, 5:30, I feel like everyone's awake, and if you come to this house at 9:00 p.m., we're fast asleep. But what gets me up in the morning is that, above all, I'm a father and a husband.

I also run the nation's largest ER diversion company, which operates 24/7, and emergencies happen throughout the night. So, depending on what's happening throughout the night, I'm either up at 2:00, 4:00, 6:00 a.m. But what fuels me, though, every day is two things. One is I want to be an excellent husband and father, and I want to be present for everything that I can, especially when I'm home what's happening in my family's life.

But two, I'm part of this company that's changing the landscape of healthcare. You know, I've been part of other companies, but this is really one of those legacy events in life where I'm building something that's really changing the way healthcare is being delivered. And I understand that's my personal mission, and that's something that I strive for every day, and because of that, that drive just comes naturally.

I'm working on something that's way bigger than me, something that my kids are going to be reading about 10, 20, 30, 40 years from now, and probably they're going to say, "Yeah, that was innovative back then [laughs], but now this is how we receive healthcare, which is awesome."

VICTORIA: That's cool. So, it's like the impact your company's having and the drive to be a part of your family and, of course, your kids waking you up in the morning. And is it all of that, or is it also the chickens? Because I had chickens growing up.

DR. LIZARDO: [laughs]

VICTORIA: And they would always, like, crow, like, really early in the morning.

DR. LIZARDO: [laughs] Yeah, Victoria, that's awesome. If you come to this house at 5:45, what you're going to see is me in a robe in the middle of a snowstorm, at least for now, going out and changing the water of the chickens. So, one of the things that we've done with our household is made it more of a sustainable household. There's a living thing in every one of these rooms in our house. There's a guava tree growing in our living room, literally, a tree from the tropics growing in Princeton. There are citrus trees growing in our dining rooms. We grow about 30 different types of vegetables and fruits on our property.

And we also have livestock like chickens, which, honestly, I think we've learned that when we see things grow, we're more inclined to try them and taste them. You know, over the weekend, we had our neighbors, and one of the neighbors was like, "You have an actual olive tree from Italy growing in your..." it's about eight feet in our family room...sorry, in the kids' playroom. They were like, "I've never seen that before." I basically told them, "You should come back in a few months and pick some olives."

We love this ecosystem that we've built around sustainability, and it basically has brought our family together in order to work on things like trying to figure out how to grow these trees inside our house and outside our house.

VICTORIA: It must be such a cool experience for your kids to see something grow from a seed into something they can eat and, interact with and enjoy. And to bring it all back, I'm wondering, what was the seed for you to decide to focus on 911 or emergency services and solving that problem that people face? And maybe describe even a little bit of, like, what is the impact of divergent and emergency room services.

DR. LIZARDO: I feel like every great leader has something personal that's attached to what's fueling them, and, in my case, it's my dad. So, my dad has a heart condition, and, you know, there's been times where they've had to call 911. In the nation right now, 911 is a very antiquated and struggling system. As a matter of fact, ambulances have become very expensive Uber drivers.

Eight out of every ten calls that's medically related to a 911 does not need an ambulance and yet uses one to go to the hospitals. Most people in the U.S. believe that if they call 911 and they get an ambulance, they're going to be expedited at the hospital, which is not true. So, I know, unfortunately, that one day, my dad's going to call 911 because he really needs it, or someone in my family will. And I'm basically building a system that when he calls, he's going to get a faster response. By doing that, by basically doing what we do, we actually take care of the low-level emergency so when the real emergencies come, they actually are able to go through.

You know, Tele911 really tackles three things, three major problems in the industry. One is basically the pipes into 911 are overflooded. Sometimes, you're put on hold. Sometimes, you call 911, and they transfer you to another state because they're just so overrun. And basically, now we're creating pipes that actually allow them to take the real emergencies.

Two, the health plans. Every health plan in the United States 80% of what they do is actually try to figure out how to keep you out of the hospital. It's called utilization management. And it's just crazy how if you look at these monster health plans, their number one rule is, 'Please don't go to the hospital,' and that's the number one thing people actually do. And, for them, what we're solving is a huge problem because now they're able to take risk and actually control their budgets a lot better and, in effect, give better rates because they know that if they call 911 unnecessarily, they're going to be treated in place.

But lastly, it's because the people that are calling 911...medical debts is the number one reason for bankruptcy in the U.S. right now, and these people that are calling 911 they're going bankrupt. If you call 911 in California, in certain counties, the ambulance is $6,000, again, 6,000, even if you use it unnecessarily, let's say for a paper cut. And what I've done is basically created a company that solves for all three: for patients that need the care and basically think 911 is the only resource, for health plans that want to control these costs, but both fall for our lines. I want our lines to be free for the true emergencies.

VICTORIA: So, it was a personal experience with your father and the need for that. And I can relate to that, as well as having elderly family members who have conditions, who regularly need support. A lot of trouble is even just getting people to the hospital, and they can have services delivered right there in their home.

Anything in the early discovery phase of trying to solve this problem that caused you to pivot your strategy in your approach?

DR. LIZARDO: Absolutely. So, Tele911 right now is the product of, you know, an idea that was written on the back of a greasy napkin [laughs] at a Bojangles in South Carolina at a medical conference. But what you see today as the nation's leading ER diversion company and one of the most successful companies in digital healthcare is a product of three failures. We actually tried this multiple times and failed. And it wasn't until COVID happened, and we realized there was an acceleration and an acceptance for video calls, that we noticed that, hey, this is actually a better way, and it can happen now.

The irony of this [chuckles] is that we didn't think it was going to work so well. When we went commercial last year, we were like, maybe we could just do 300 calls. And in exchange, we started doing this by the thousands. A few months in, we're in the several thousands, and we're like, oh my God, this is working. And then, by the end of the year, we covered over 5 million lives by geography, and I realized we're on to something. Legislations passed with our name on it. So, you know, this idea that struggled, and we had to restart multiple times, we did not give up. And in exchange, I mean, we're literally making history.

VICTORIA: I love that. Yeah, so pre-COVID the idea of having medical services delivered virtually, I wonder what feedback you got from investors or from people interested in the idea at that time.

DR. LIZARDO: [laughs] No one wanted it [laughs]. No one wanted, you know, you show up to someone's house, and they're like, "Yeah, we're not going to take you to the hospital. We're going to have you see a doctor on the screen." They would be like, "No, I'm going," right? [laughs] Like, "This is not working." Also, even the counties, they were like, "This is too risky. What do you mean the doctor's going to be on the screen?" There wasn't a high level of adoption for something like this, and, you know, it struggled a lot.

I recall pitching the idea and people coming back to me and saying, "Well, you know, I love this. Tell me when it works. Tell me when you have enough traction." You know, it's funny because those are the same people now that are on our waitlist who now basically really need this, really want this, but we let them know there are 35 million more lives in coverage based on the counties just in our waitlist. It's a testament to just how awesome this product is and how fast it's adopted, but also the true need for something like this as part of the healthcare delivery continuum.

VICTORIA: Wow. Yeah. That's incredible that once you found the right fit, it became acceptable and even necessary to receive care virtually during the pandemic, and it really took off. So, now that you've gotten some initial traction and more than enough, what are your challenges that you see on the horizon?

DR. LIZARDO: So, a few challenges. Let's talk about how this went from, hey, a good idea to now a standard across different states. So, for example, in certain counties, and, I mean, this happens in every state as well. I'll give you an example of Florida. The hospitals are literally two hours away. Florida is incredibly rural. They either are able to see a doctor through our telemedicine platform, or they have to go on an ambulance for two hours, and that ambulance is away for six hours, like an entire shift.

So, one of the things that I've seen is a huge challenge is our product has grown expansively. So, what we do is we're basically building a larger network to be able to deliver for a larger volume. By the way, every time someone presses that button, within 40 seconds, on average, you get an emergency medicine physician that's board-certified in that state. And, I mean, that number used to be 2 minutes, then 1 minute, and now we're at 40 seconds. Eventually, it's going to be 10 seconds.

I'm pretty sure myself, someone who worked in emergency medicine, can't reach my friend in 10 seconds [chuckles], but this product does, which is what's fascinating about it, that high level of care. But with that same issue, we're now doing this for the tens of thousands. And within the next two years, we're going to be doing this for the hundreds, you know, we're forecasting hundreds of thousands of calls.

So, how do we prepare for that? How many emergency medicine physicians are in the U.S.? Can we cover those amount of lives? You know, do we continue to expand across auxiliary like APNs and higher tiers below MDs? So, these are the kind of things that I have to constantly think about. These are the kind of things that the government now reaches out to me to just get some advice on. Everyone's approved this. Now it's more, how do we scale this as we continue to make this the gold standard?

VICTORIA: The scaling becomes a top priority. And as a CEO who needs to build a management team around yourself, how do you identify where you have needs and where to find the people to perform the task you need to scale?

DR. LIZARDO: That really does depend on the role. One of the good I used to sit on clinical boards for about 16 health plans, which allows me to have a very expansive network, particularly within healthcare and products. So, I know that the people are out there. The thing is, working at Tele911 is a very different type of environment than most people are used to. Here, we really fall fast collectively, lick our wounds, and redirect together.

Everyone has access to me. There's no hierarchy. It's more of a matrix environment, at least at this level. And then I tend to hire people at the management level that don't look like people that you would generally hire, and the reason is that there are two factors in order to be successful here at Tele911. You have to have that human component; to me, that's important. A lot of the people here...actually, I was sharing this with someone, but for the majority of my tenure here at Tele911, I was actually the youngest person at the company. I hire people with tenure and wisdom.

But a lot of the types of people that I hire here are actually outside of the industry, people who can bring in those thought processes over to Tele911 across repeatability, monetization, and scalability. Some of them are from manufacturing. Some of really does depend. But when I look around the team, and I'm like, wow, you know, we are a team of misfits, but we produce amazing results. I mean, Tele911 in the last year alone, 3x volume and 5x just billing. So, we understand that we are part of something unique, and people just bring their ideas into that and adapt to it.

VICTORIA: Your approach, it sounds like, to play it back a little bit, is to find people who are smarter than you [laughs] about some things and then, yeah, really reach for wisdom and not fall into the same pattern that other organizations may be advised to follow to build their team because you have that insight into your market and your industry, and you can navigate what you need in order to scale.

DR. LIZARDO: Yeah. Also, at Tele911, this is innovation. So, there's really nowhere else to look for talent who have done this before. So, we really have to outsource from different industries. You know that adaptability is key, but what I really look for is repeatability. Has this person been ingrained with figuring out the pieces that make it whole and basically integrating them into our process, repeatable, monetizable, and scalable?

VICTORIA: Right. And maybe that answers my next question, but what core values drive your everyday decisions?

DR. LIZARDO: As I said before, and I think I said it at the beginning of the call, people know me as a father and a husband. That's who I am, and above all, that's my number one job. So, that human component is so critical in order for you to succeed here. Life happens while you're at Tele911. Parents get sick; kids have the flu; like, life happens.

And we have to understand that this is an empathetic environment. Someone in the management team had a baby today, and we were at a debrief meeting. And in the middle of a meeting, someone said, "The baby is here," [laughs] and everyone was rejoicing. If someone externally would have been in that meeting, they're like, "Who's baby, and why are we announcing it in the middle of a management meeting?" But, to us, is we function as a family, which is critical.

Another value that we really stress here is integrity. Because we're part of innovation, we have to be very clear about our numbers and very clear about how we're achieving our traction [inaudible 18:24]. I'm not really interested in the goal. I'm more interested in the process, but be very, very clear. You have to be creative. You know, I spent some time studying quantitative methodology over at Harvard, and repeatability is important, but being able to think outside the box because, again, this has never been done before. So, you have to look at this from an angle of, like, the art of the impossible, and then go and try it.

VICTORIA: Right, yeah. And I think it's really interesting, too, like, you know, when you think about making art or innovation, you can sometimes look and see how other people have done it. But then you have to decide what's your path. And, like, how do you solve for this particular problem? And, like, what can you learn from these [inaudible 19:08] this is the way you should or shouldn't do that; practice is really interesting, I think.

DR. LIZARDO: You know what? And I think that's probably been the most exciting part about this. I've never been in a situation where there was nothing to look back to reference. Like this is the first time in history that this is going, and it's accelerated so fast. We don't have a, hey, this is what good looks like. We basically have us, and we've had to adapt to that.

And along the way, what we've done is we've basically done basic, like, micro-moments of learning, adding on to those and saying, "Okay, this is what good looks like. But then what would great look like?" And I think that that's the example of...remember when I mentioned earlier, you know, it used to be 2 minutes, and 1 minute, you know, then 50 seconds, now 40 seconds. And we're like, "Hey, what if we could do 10 seconds where people press a button and get a board-certified doctor upon a 911 call?" And you're just like, yeah, that sounds impossible, but so did this idea now. So, we know the art of the impossible is just a few stone throws away as we continue to make traction.

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VICTORIA: You know, there's the impact for the person experiencing an emergency and having it be able to resolve within their home. It also opens up that possibility of remote work for doctors and nurses, which I'm sure you know more than me about the current state of the strain on our medical system and the people who are working in it and how you think about the impact on them as well.

DR. LIZARDO: Just for context, my wife is a physician. And during COVID, we ended up having two kids, one right before and one during. And because of our–one–our parenting style but also our life choices, what we basically is we took turns at different points in order to stay home with our kids. But one of the things that, you know, have always bugged me is we saw every specialty practice virtually, but emergency medicine had to be practiced in the hospital. And unfortunately, because of that force and that strain in the system, less than 50% of the spots in emergency medicines were filled last year. People don't want to do it.

So, what we did is we went out to a lot of these parents and said, "Hey, do you want to join this network where you're able to see patients while you take a nap virtually?" And they're like, "Whoa, let me try that." And, Victoria, within three weeks, dads and moms were showing up in droves with their babies to the interviews, saying, "This is what my life looks like. He takes a nap between 2:00 and 4:00. Can I grab a shift for those 2 hours?"

And along the way, we ended up building the nation's largest virtual emergency medicine practice. Out of that pain point in us and just asking questions, we built this awesome system that now propels people to basically press a button and within 40 seconds, get a doctor. And I think that's the art of the impossible. We actually look at it and say, "Well, we could probably do something better on that."

But we've also now reshaped emergency medicine to the point that now we're the ones that are writing the fellowship for virtual emergency medicine. We are now creating the protocols and our data now is in journals as, hey, this is what the specialty should look like, and this is what they're able to do. So, we're equally as excited about that and just on the outcome. And it's just a huge honor.

VICTORIA: Wow, that's incredible that it would go in that direction, and you'd have this opportunity to really reshape an industry and define how even people learn how to perform emergency services and medicine.

DR. LIZARDO: [laughs] You know what the most amazing thing is? It's actually a lot easier than what other specialties have done because cardiologists have been able to, you know, see patients virtually, but they can't do an EKG. But our team can because the medics are on-site within 8 to 10 minutes of that call, and they're able to do an EKG. They're able to do a pulse ox. They're able to even do an IV drip. So, it's actually a new way to practice emergency medicine, where the medic is your hands, eyes, ears, but the doctor's basically working in conjunction with them, guiding them to best do the assessment.

VICTORIA: That's, like, such a revolutionary idea, and I think it's so cool. I'm curious: how do you perform user research and design for patients and for emergency responders?

DR. LIZARDO: [laughs] That's a question that we're actually working through right now. So, emergency responders they actually all have an iPad or a computer on them when they show up at your house. But that looks a lot more like the Nokia phone, the blue phone from back in the day. There's very little interaction on that iPad. And what we've done is we've put an app that's dynamic that allows them to basically best assess the patient, understand their protocol. So, it actually has its enhancer experience.

Also, remember, these medics are some of the smartest people on earth. I mean, they see patients more than doctors do. They know where they live. They know what their house looks like, and they've seen them thousands of times. So, what they're really good at is interacting with the iPad in a way that actually shows the surrounding, shows the patient, and shows what's important.

When it comes to our doctors, particularly in emergency medicine, they've been dying to basically practice virtual emergency medicine. So, what we've done is we've basically provided the initial data set of what they need, along with a video. But now we're actually augmenting that with additional data sets that allow them just to have a more comprehensive picture of the patient, including some look back data, what happened before, what should be happening afterwards, integration with their health plan. They actually have more data and a better experience with practicing in their home than if they were at the hospital.

VICTORIA: I appreciate that viewpoint. And I can understand how interesting it must be to design for those two different user personas. I'm curious; you mentioned data. What's your strategy around data privacy, and protection, and security in your application when you're at the same time trying to be very innovative and move very quickly?

DR. LIZARDO: Well, you know, I've always believed data is on a need-to-know basis, particularly because we're dealing with PHI. We're dealing with clinical data. I always tell people it's one thing for someone to walk into a hospital and tell you their name, last name, phone numbers. It's a whole other thing for you to go to their home and start gathering information. So, that is basically one of our key standards here.

We understand the gravity of the data that we're collecting and how critical it is, not only to health plans, health systems, but, above all, the member and how that privacy should be kept. And it's such a critical component to the company. As we continue to grow and mature, we've added additional layers in order to best protect the company–but above all, best protect the member in situations like this.

VICTORIA: Yeah, well, I appreciate that viewpoint. And starting, you know, probably your background as a consultant and also working as a doctor, you have a really deep understanding of the type of data you're dealing with and how sensitive it is. So, I appreciate that that's a priority for you within the company. What is the wind in your sails? What keeps you going? What keeps you committed to doing this work?

DR. LIZARDO: So, at this point, we are reshaping an entire history. We're literally going in the books now. So, now we can't stop this. I remember going through medical school and reading through some books. I was joining part of a community of doctors. Now, I'm rewriting and creating a new version of how this entire industry is being practiced. And understanding the gravity of such a monumental place in society that keeps me going. We can't stop it now. And that, to me, is what's monumental in all of this.

VICTORIA: That's great. So, it's that big overall vision of the impact you're making on not just a few people, a few million people, but really the whole industry and for many years to come.

DR LIZARDO: Exactly. Exactly. So, just so you know, for example, our patients aren't just...we don't just do emergency medicine. Some of our patients have psychiatric needs, and some of our patients have, you know, oncological needs. So, we are actually the largest lead generator of patients into the right system for the United States because we're capturing them at the 911 call. So, there are so many great companies out there, and their number one problem is not how to solve for the things that they build; it's who's going to use it. How do you find more customers to actually use it?

And what a lot of these companies have realized is, hey, we've been trying to find these people for years, and yet they're walking into Tele911's front door. How do we partner up with them, and how do we basically show Tele911 the services that differentiate us in order for them to walk the patients towards us?

VICTORIA: That's such a cool stat to have that you're really putting people into the right path. And you have these great things that you all have achieved. I wonder, do you write key objectives and results? Because some of those it sounds like, well, I don't know you would ever be able to dream up that result [laughs], right?

DR. LIZARDO: Yeah. Well, yeah, we do function. We actually have a KPI doc that we use. We all track, and everyone at the company has visibility into them. It's super critical for everyone to be aligned no matter the level for that. I always say KPIs should not be unachievable, but they should be a stretch. Tele911 expects to grow 10x on its second year; very, very, very few companies in the history of digital health have grown 10x. And we are not only with foresight of, like, how we're going to achieve that; we're actually executing on a trajectory for that 10x.

That's a dangerous number to say for me as a CEO. And I look at the KPIs, and I'm like, well, we did 5x last year and cut almost a million in operating costs, so we can do 10x this year. Any consultant outside would be like, "Yeah, that's crazy," and then they look at our model, and they're like, "Yeah, these people might be crazy enough to actually do it [laughs]."

VICTORIA: Well, that's great. I mean, and, I guess, it's, like, all about how do you picture it? Like, are you trying to make a goal that gets everyone excited and gets everyone motivated and dreaming of the art of the possible, or are you just trying to make it so that you can check it off at the end of the year [laughs], right?

DR. LIZARDO: No. Actually, checking things off is...listen, at the end of the year, we're looking at the following year's list, right? We're not just checking things off. What we're doing is, we understand our mission, and because of our mission, what we're saying is, how aligned with our mission are we? I don't know if that's a circle or a checkpoint, but it's more about alignment for that mission of democratizing access to the best care as fast as possible upon a 911 call.

VICTORIA: I love that. That makes a lot of sense to me, just bringing it all back to the mission and the impact and why we're all here in the first place, right?

DR. LIZARDO: Exactly.

VICTORIA: I love that. Wonderful. Do you have any questions for me?

DR. LIZARDO: No. I mean, it was excellent to, one, just to be able to connect with you, two, to be...actually, as I was talking through these questions with you, you know, I realized how...just for context, my favorite author is Walter Isaacson. If you ever have the chance, please read one of his books. I'm reading Benjamin Franklin, and I read Steve Jobs' book. There's actually a few books. My favorite book in the whole world is Da Vinci by Walter Isaacson.

And, you know, I hope that people listening to this they can do two things. One, they can get to know me just a little bit and the things that we're doing, but two, they can be inspired because I think that's what we really need. There's a lot of people starting companies just because someone's doing something they could do it better. I mean, that's cool and all, but just so you know, most of those things actually fail. There's a reason why 9 out of 10 companies actually fail today. We don't need more copycats. Think of the art of the impossible and create that, and then pursue it as if nothing's holding you back. And if you do so, you just might find yourself with a Tele911 company.

VICTORIA: Well, that gets me fired up. I'm excited. I really love that advice. I appreciate you sharing that with us. Is there anything else that you would like to promote today?

DR. LIZARDO: Yes. If I could just take a second to share about this, I know that a lot of people who listen to this podcast want to start companies. A lot of people are trying to figure out, how do I get my idea started? But I also realized a lot of these people really haven't written down their ideas. They're basically pursuing things that haven't really been written down.

And one of the things that I shared, if we go back to this podcast, I said, this idea was written on the back of a greasy napkin in South Carolina during a storm at a Bojangles. I literally recall seasoned fries, dipping it in the grease of the chicken, which is terrible for you, by the way, cleaning my hands, and writing on the back: What if people call 911 and this and this and this happened?

And if I could leave you with one thing is, please write your ideas down. Send me photos of your napkins [chuckles], like, share napkins with people on a plane, people on a train, share these ideas, write them down. Because the ideas that write them down basically have an opportunity to go back and reestablish, to modify. But one of the things that I know is these ideas eventually echo in eternity at one place or another. And when I leave, just with an encouragement, please just write your ideas down.

VICTORIA: Great advice. I really appreciate that. You know, everything in moderation. I'm not going to say fried chicken or fries is bad for you [laughter] because I like it.

DR. LIZARDO: [laughs]

VICTORIA: But yeah, no, thank you so much. I loved sharing with that and, hopefully, people will share your ideas.

You can subscribe to the show and find notes along with a complete transcript for this episode at If you have questions or comments, email us at And you can find me on X, formerly known as Twitter, @victori_ousg.

This podcast is brought to you by thoughtbot and produced and edited by Mandy Moore. Thanks for listening. See you next time.


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