Alex Oshmyansky MD PhD is an early-career teleradiologist at Vision Radiology, husband, and founder of Osh’s Affordable Pharmaceuticals. We joined him for coffee at Coupa Cafe in downtown Palo Alto to find out how he does it all.
Why did you choose teleradiology as your first job after fellowship?
I’ve always had a streak of entrepreneurial and other side projects — teleradiology was the best way to sustain those interests. Plus, I get to live with my wife on the Big Island in Hawaii, which is pretty amazing.
The ability to fully customize my schedule makes for extraordinary flexibility. For example, I also started Osh’s Affordable Pharmaceuticals this past year to create affordable generic drugs, and went through the extremely-selective YCombinator incubator program in Silicon Valley. I’m also an adjunct faculty at Stanford where I help bring new medical technology to market.
To give you a sense for my schedule, I work teleradiology for Vision Radiology from 9pm to 5am Pacific Time. During the day, I work on my startup. And I’m able to adjust the number of shifts I work.
How is your teleradiology group Vision Radiology organized?
We’re about 40–50 radiologists, and our core value is high-quality interpretations. We recruit heavily from Hopkins and Stanford. One of our signature features is that we call the referring physician in almost every case — even chest x-rays, although most of our volume is CTs. We contract with a range of hospitals from academic medical centers like Stanford to rural community hospitals.
Our team is very close-knit and academically oriented, working collaboratively and learning from each other over the course of our careers.
Our team is very close-knit and academically oriented, working collaboratively and learning from each other over the course of our careers. For example, we run an accredited biweekly lecture-based CME program for our radiologists, where we teach each other latest advances. (I can’t always make those lectures, which isn’t a big deal for CME, since I use Orbit to close the gap. )
By creatively taking advantage of timezones, nobody in the group works a true overnight shift. We do have to stay credentialed in multiple states, but my enterprise account with Orbit automatically lets me know when I have a license renewal coming up, or if I need to claim more articles for credit this month.
How did Vision Radiology start?
Gautam Agrawal and Raymond Hsu founded the company 15 years ago, after they finished training at Hopkins Radiology. It’s insane how hard those guys work — they’re reading full time, and they run the non-clinical parts of the business. Gautam and Raymond are also great role models as entrepreneurs, and they’ve been incredibly supportive of my interests in business.
Isn’t it hard to call the referring physician for every case? Do they even like that?
Most of our cases are from the emergency room, and generally the ER front desk routes my calls rapidly to the ER attending. And it turns out that ER doctors really appreciate being called about cases. It helps to build the relationship and accelerate patient care.
How is life on the Big Island?
I tried the thing in Hawaii where I just laid on the beach, but with my personality I need to be occupied at all times, hence the startup stuff. I used to do ultra-marathons — the longest I attempted was the Comrades marathon in South Africa back in my 20s, so I’m going to get back into trail running, and I’ll probably try Hawaiian outrigger canoeing.
Were you affected by the recent volcanic activity there?
We live 30–50 miles north of the volcano, so the eruptions weren’t too bad. We felt earthquakes, but not the volcano’s direct effects. The cruise ships did stop coming for a few months, which was an unfortunate hit to local tourism. But for 99% of the island, there hasn’t been much direct effect.
How did you meet your wife in the middle of a massively busy schedule?
Well, technology — we met online on Match.com in 2011 and hit it off from there. At the time, I was in residency at Hopkins, and she was a medical student at the University of Maryland in Baltimore. We actually got married in Colorado just two days after YCombinator ended.
What was your training path into your dual career in teleradiology and entrepreneurship?
I completed my MD at Duke, where expanded my third year into a PhD in Mathematics at Oxford funded by the Marshall Scholarship. At Oxford, I worked on mathematical modeling of seizure prediction in the brain using cellular automata. After a surgery internship year at the Brigham, I did my residency at Hopkins (2010–2014) and my fellowship at Hopkins in interventional radiology (2014–2015). I finished YCombinator in Spring of 2018.
What in the world are cellular automata?
Cellular automata are just a way of simulating physical systems, where local rules propagate into global phenomena. It was previously popularized by Stephen Wolfram. You might of heard of The Game of Life which is a cellular automaton that simulates evolution. Each element on a grid has a rule. Local rules then propagate into global phenomena. I coded most of my work in Matlab and drew on numerical methods, so it’s kind of similar to simulating partial differential equations in that way.
Why didn’t you end up in academic radiology?
I was very close to winding up in academic radiology. I find that private financing works a lot faster, and otherwise it’s not too dissimilar from the academic mindset. It’s becoming more that way, especially with university technology transfer, where faculty patent their research and then license those patents to big companies or their own startups. I also like the independence of being able to operate without bureaucracy.
Our idea with Osh’s Affordable Pharmaceuticals is to bring down the high cost of creating generic drugs using pharmaceutical compounding.
What is your new YCombinator company working on?
Our idea with Osh’s Affordable Pharmaceuticals is to bring down the high cost of creating generic drugs using pharmaceutical compounding. There are many drugs that are off patent but still cost thousands of dollars per month. Many of these expensive generics are life-saving formulations that people need, but the process of creating a generic is slow and expensive. We’re trying to solve that.
Had you started companies before Osh’s Affordable Pharmaceuticals?
Actually, yes. I started a company, Altitude Medical, during graduate school. We made patent-protected door handles that dispensed hand sanitizer. We set up an independent clinical trial at Hopkins which was great, but that was a multi-year process, and it showed me the inertia of large institutions. We’re coming up on Altitude’s ten-year anniversary. It’s currently run by a great team focused on the food sector, but I’m not involved in day-to-day stuff.
Do you think you’d ever stop radiology and do business exclusively?
No. I don’t think I’ll ever stop practicing as long as I’m doing medical startup work. if you do medical startups, it’s important to be a practicing doctor. Your practice grounds you, and keeps you focused on patient-relevant goals. Your practice also helps you understand how the system works in broad strokes. If you’re coming in from the outside of the healthcare system, the system can appear opaque.
Why are some generic drugs so expensive? Aren’t they off-patent?
Unfortunately off-patent doesn’t automatically mean cheap, and there are a number of reasons for that. For example, one factor for the high cost of generics is that companies that currently manufacture generics can manipulate the FDA Abbreviated New Drug Application (ANDA) process to avoid competition.
A new company needs samples of an existing non-generic drug to show that their new generic version is bio-equivalent, and exists at the same concentrations in the blood stream as part of the FDA approval process. But many drug companies don’t make samples of their drugs available to companies trying to create generics. The FDA tried to help out by publishing a “shame list” to expose companies that have denied requests for samples. Public shaming helps, but it doesn’t solve the problem.
So how will your startup create generic drugs with lower friction?
Instead of the FDA pathway, we’re using the pharmaceutical compounding pathway to get generics approved. I actually got interested in this approach after I was disgusted by Martin Shkreli’s behavior with daraprim. Shkreli was charging $750 per dose, and in response, a San Diego compounding company called Imprimis put out a $1 version of the drug.
The San Diego compounding company’s response was inspiring. We’re taking a broader view, and using compounding to drop the cost of expensive generic drugs across the board. I’m convinced that generics can and should be affordable.
What was your most memorable lesson from YCombinator?
Focus on your products and your customers. See what they want. Talk to them constantly. If they don’t like something, then change it until you find what works. There’s an intellectual purity to this. Their motto also encapsulates their philosophy: “make something people want”, and then of course tell them you have it.
Their other lesson, iterate quickly, works better for tech than drug development.
Would you recommend YCombinator to other radiologists looking to start companies?
Yes, particularly if you’re already gotten your company started on the journey to finding product-market fit. I started Osh’s about a year before I joined YCombinator, and exploring your market beforehand helps strengthen your application and gets you ready to absorb more from the experience.
YCombinator is also very good at inspiring you to work hard. And I like to think at least that I’m already a hard worker too — I chose to do my internship year in surgery voluntarily. The YCombinator experience also increased the value of my company, as did their network and teaching.
But if you can’t take several months off to move to Mountain View, or if you don’t get selected, don’t let that stop you from pursuing your dream. Just be ready to work non-stop, regardless of how you start your company.
Have you already raised money for Osh’s?
Yes, we have investors. At the end of YCombinator, they have a demo day where investors are invited to attend, so that makes fundraising easier. Right now, we have the money to start a physical facility, which I hope to have built out by middle of next year.
What are your favorite software tools to help you get through a busy day?
I use Google Calendar and Google Tasks for my to-do list. Google recently integrated Tasks into the side menu of Calendar, which makes it easy to access.
For CME, Orbit makes earning and tracking credit a complete non-issue. There’s also personalized article recommendations and reminders in the enterprise version. Since I have licenses in 10+ states, it’s great to have Orbit give me a heads up when a renewal deadline is approaching.
What’s your parting advice to early-career radiologists interested in entrepreneurship?
Find a supportive employer. If I was with a generic private practice, there would be no way for this to happen.
— Orbit Staff
Radiologists in Orbit is a new series on Orbit power-users who are discovering freedom and meaning in this new world of radiology practice that presents adversarial change — business, reimbursement, AI — but also positive trends — work-life balance, more jobs, subspecialty opportunities.
To nominate yourself or another provider to be featured in Radiologists in Orbit, email us at email@example.com and tell us how you (or they) build work efficiency and pursue life beyond the reading room.