A Violent Encounter With Transparency And Other Adventures In Biotech Fund Management: My Unofficial Investor Letter 2017
Reliable Deli is on the north side of East 54th Street, midway between Park and Madison. It has a rust-colored awning with white lettering, with a string of Christmas lights strung around its edges that blink on and off year-round. I've gone there four or five times a week to take out breakfast or lunch for the past 8 years. It's a bustling place, one of those places where you can get hot food, cold food, toothpaste, batteries, boxes of cereal, sandwiches, wraps, spicy Korean chicken, fake crab meat, and real duck. Deep metal pans under heat lamps. Sneeze shields over the buffets.
You get the idea.
Reliable has two tall glass doors that can swing in or out, like saloon doors, only much thicker and much heavier. One day this summer I must have had difficulty deciding which way I wanted to open the door so I just walked into it as if it wasn’t there. Right knee and forehead met the thick, thankfully shatterproof glass while I accelerated from a standing start. I bounced off the door, shook my head back and forth like a puppy hearing itself bark for the first time, while soaking up the collective concern and secondary embarrassment of everyone inside.
The staff sprung into action. A small stack of clean napkins was quickly applied to my forehead. A first aid kit appeared, its contents probably long expired. A heavily accented New York voice repeated over and over: “Get him to an emergency room. He needs an MRI. I'm a nurse. I know”
I had no intention of going anywhere except back to my office across the street. I felt okay. I am not a stranger to concussions, having suffered one while ice skating with my son years ago, and I somehow knew that the door had enough give to have not made my brain rattle around inside my head. The skin on my forehead, however, was not so fortunate. Just to left to the midline on the mild frontal bossing over my eyebrow there was a terrific gash, the result of the impact followed by a little bit of a smush and tear. I folded the stack of napkins to hide the soaked-through part, applied pressure again and this time successfully exited Reliable Deli.
I was quite a sight in the elevator, going back to the office, holding a white plastic bag containing the styrofoam container with my lunch in one hand and the other hand pressing the folded stack of bright napkins against my forehead. Thirty minutes later I sat in the exam room of a nearby urgent care center. A half hour after that I am back on the sidewalk, having replaced the paper dinner napkins with a folded stack of sterile gauze pressed against my forehead, dismissed from the Urgent Care Center and directed to the nearest emergency room. (“Too deep. And you need an MRI.”) I stood on Second Avenue, left hand against head, right hand holding cell phone, speaking to a helpful representative of my insurance company, who reassured me that as far as United Healthcare was concerned, I could choose between the equidistant emergency departments of Cornell Medical Center and NYU Medical Center, confident in the knowledge that my co-payment, deductible, access to care for the rest of my life, and future list of pre-existing conditions would be the same.
I went north to Cornell. “I used to work here,” I said over and over, eliciting a flash of semi-interest from the security guard at the door, the triage nurse, the admitting nurse, the intern who took my history, the attending who retook my history, and the volunteer whose job seemed to be to observe me for any signs of rapid cognitive decline.
I turned down the MRI and was content to let the intern place four interrupted stitches (it may have been silk or vicryl but I forget) into my forehead, although I was offered a plastic surgery consult. At that stage in my training, I could have thrown those stitches in my sleep. The intern’s handwriting was good so I figured his hands were steady.
I returned to the office with a bandage wrapped tightly around my head, returned to the ER a few days later to have the stitches removed, filled out a nice evaluation online about the quality of my treatment at the hospital, and ignored the monthly solicitations for donations that came for the rest of the year.
The next day, I was a celebrity at Reliable. Breakfast was on the house, as was lunch. The cashiers, the short order cooks, the stock guys all greeted me with warm smiles and curious glances to the scar on my forehead. Menus were taped on the glass doors at eye level.
I made a point of joking about the incident and repeating over and over again that I had been careless and preoccupied and stupid and that it was my fault. And that I was fine, no crazier than before, no ringing in the ears, and certainly no intention of talking with a lawyer.
After a few weeks, the menus came off of the glass doors, and the customers of Reliable Deli were again trusted to use their hands or back sides to enter and exit. The scar slightly to the left of the midline just above my eyebrow faded away. The Intern, who by now has rotated to the Intensive Care Unit or to one of the med-surg floors, had done a good job. Whatever acute or chronic damage that my brief violent encounter with the glass door may have caused will forever remain undetected by the MRI scan that I refused to have done.
Every semester, as my students get to know me better, their questions get more and more personal. Towards the end of each semester I get asked wisdom questions, about success and happiness. I’m no expert, but I do think that humility and the ability to laugh at yourself are good places to start. Also: the fund did just fine this year.
A couple of decades back, a senior surgeon handed me a scalpel, addressed me as doctor, and told me to make my very first incision. My hand and the knife then hovered over the patient's abdomen like a helicopter over a traffic accident before finally taking a timid swipe and barely scratching the skin. My colleague waited patiently for me to shake off my nervousness, and a couple of hours later, the patient and I—an intern—were both in stable condition in the recovery room.
Now I sit at my desk—a grid of PowerPoint slides on one computer monitor, my course outline on the other. I am a novice again, midway through the 28 lectures that I will present this spring. Only for the moment, I'm doing a lot of staring and very little PowerPointing, and the prospect of teaching an entire course for the first time seems far more daunting than performing surgery. Medicine is a teaching culture. Second-year students show first-year students how to throw square knots, interns give impromptu seminars on fluid management during quiet moments in the intensive care unit, and bow-tied internists happily demonstrate the secrets hidden in the patterns of filling and drainage of neck veins to the first orderly or flower-cart pushing volunteer who happens to walk by.
I left medicine a few years ago but continued to teach: an occasional hospital grand rounds where I had trained or lectured to science or business students. Now I agonize over decisions that experienced instructors take for granted. In a few weeks I will teach my "Entrepreneurship in Biotechnology" students the 10/20/30 rule of effective presentation: 10 slides in 20 minutes using a 30-point font. Of course, my first lecture has 33 slides, but I rationalize that the first few are throwaway office hours / grade consists of / last day for drop-add types. Lecture two has only five slides so far, but I need to leave time for student presentations. Each presentation should last one minute, followed by two to three minutes of discussion. Four minutes per student unless the discussions get detailed and deep—but what would be wrong with that? Nothing—but what if the discussion is superficial and belabors the obvious? Or what if there is no discussion at all, just the kind of sinking silence that happens in comedy clubs when the comedian completely loses the audience, and everyone knows that he can't win them back but also knows that he has to try and that they have to sit through it?
Tonight I struggle with week one. The slides are unformatted black on white, with a little line at the bottom with the course number and "Columbia University GSAS" in small font. The slides appear in neat rows across the screen, but their concepts and ideas somehow remain hidden—the presentation a puzzle with all the pieces the same shape and no clues as to their correct order. One of the business-world clichés that I will relate (though not necessarily endorse) is that a presentation needs to be delivered 25 times before it makes sense. I am unwilling to sacrifice coherence for my first 24 semesters, however, so I devise different practice methods. Most often, I lecture to two dogs in an otherwise empty room. Weeks one and two are almost ready, but week three is not even close.
My students-to-be are an extremely smart group: a mixture of undergrads, masters, and Ph.D.s in the sciences, hoping to cram as much of a business education as they can into one semester. I worry about letting them down. I focus on them and try to anticipate their expectations. I stop polishing my delivery and start listening for clarity. Suddenly the teacher's block breaks, and a few of the slides almost jump off the screen and beg to be moved elsewhere. Quickly, week three is almost clear—its transitions logical and its conclusions evident.
My process is evident as well: course outline on one screen, slides on the other, practice out loud in an empty room, dogs optional. Listen for what your students will hear, and make it logical for them to understand. Repeat as needed.
Ray Bradbury once said that living at risk is jumping off the cliff and building your wings on the way down. I used to think that cliff jumping was a young person's sport, but I still find myself walking along edges, blueprints in hand.
Distracted by a report by an analyst I do not know about a company I do not own in an industry I do not cover, with Claudio Arrau playing Chopin in my head, oblivious to a truck backing out of a hidden garage, I felt the nudge of a fellow pedestrian’s shoulder just in time to look up and veer out of the way.
It’s a relief when unseen forces erase danger, reinforcing that child-like feeling that God or the government or some all-knowing future mentor exists, solely for my protection and guidance.
Of course before I reached Fifth Avenue the magical thoughts were gone and I knew that I had better keep either my eyes or my ears on the road ahead. So I clicked away the analyst report and let the music play.
I like Chopin when played on an almost out-of-tune piano half an hour before last call in an nineteenth-century Parisan tavern, drunken and romantic. My near collision with the truck coincided with the horn fanfare that transitions the Andante Spiniato to the Grande Polannaise. Soon after the piano returned: a sad song from the right hand balanced by ringing, triumphant chords from the left. The two themes danced around each other, sorrow and triumph; the pianist taunting us with almost-missed entrances and barely audible notes. The music floated to an inevitable conclusion of sprints up and down the keyboard, and grand chords that pushed open the revolving door to my building and made me smile. I arrived at work, chastened for my inattention but grateful that triumph and sorrow together can still equal joy.
David Sable MD
writer, teacher, fund manager and retired reproductive endocrinologist