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Bridging Access Challenges for Maternal Mental Health in California

Note: This was cross-posted on the Beacon Lens website on April 24, 2018.

There must be something in the water in Beacon Health Options’s San Francisco office. Over the past year, several of us who share the space have had baby girls (me included). As an expectant and now new mom, I have experienced the health care system as a patient – not just as a behind-the-scenes professional.

At my first postnatal appointment, the nurse checking me in handed me a clipboard with some familiar questions – an Edinburgh scale to measure my risk for postpartum depression. While I often chuckle at how slow technology has been to enter the clinical workflow, especially in San Francisco, I was glad to see that my OB-GYN was taking the question of maternal mental health seriously.

System stakeholders focus on maternal mental health

The good news is that my doctor’s office is part of a growing focus in California by clinicians, funders, advocacy groups, health plans and now state legislators on maternal mental health, starting with screening. Advocacy groups such as Maternal Mental Health Now and 2020 Mom have prepared reports on the issue and have designed clinician trainings. Funders such as the David & Lucile Packard Foundation have looked at how technology can play a role (I helped contribute to this effort, with a mobile mood reporting app), and groups such as the California Health Care Foundation are looking to incorporate mental health into their broader focus on maternal well-being. There has even been legislative activity advocating for support and programs for women.

Furthermore, maternal mental health is very much an issue of geography. Research by Dr. Jennifer Rienks of the Family Health Outcomes Project at University of California, San Francisco, shows that there is a growing regional disparity, with higher mental health diagnosis rates in the more rural parts of the state. Therefore, any solution needs to leverage new tools and models for under-resourced regions as well.

MCPAP for Moms

From Beacon’s perspective, and from my experience as a new mom, screening is only effective when there are resources to support women at risk for, or diagnosed with, a postpartum mental health condition. The good news is that Beacon has a great model from our Massachusetts colleagues, where Dr. John Straus, Beacon Associate Medical Director, and Dr. Nancy Byatt, Associate Professor of Psychiatry, OB/GYN, and Quantitative Health Sciences at the University of Massachusetts Medical School, have expanded the original Massachusetts Child Psychiatry Access Program (MCPAP) to OB-GYNs through MCPAP for Moms. The program provides real-time psychiatric consults to primary care physicians, pediatricians and OB-GYNs through a series of hubs staffed with a psychiatrist, a care coordinator, and a navigation support professional.

From Beacon’s perspective, and from my experience as a new mom, screening is only effective when there are resources to support women at risk for, or diagnosed with, a postpartum mental health condition.

Beacon has adapted the MCPAP model into our new Cal Consults program. We are working with many of the stakeholders above to launch our first maternal health hub in 2019. We are fortunate to have partners who believe in this model and the potential to expand services by making the next step after a screening as easy as a consultative phone call. Beacon’s California team is excited about these efforts, and is hopeful that, by the time the next Beacon baby is born in San Francisco, follow-up screening will be not only a form but an action plan and complement of services too (and maybe even a mobile app)!

Interested in learning more? Dr. Rienks and Dr. Straus will be presenting on the state of maternal health in California and the MCPAP for Moms model during a webinar on May 16th. Learn more and register here.

VC-backed Baby: Part 1 - Conception

When I first moved to San Francisco in the early twenty-teens, a few friends and I started a google doc to support our “VC-funded Life.” As tech-savvy start up employees with more options than dollars, we were well-positioned to take advantage of the eCommerce and Gig economy. We tried all the start ups dedicated to making sure we never had to leave our couches - and appreciated all the VC dollars that were used to fund customer acquisition. 

A few years later, my time in SF has outlasted some of those companies (RIP Sprig, Washio), and my needs have changed. As the pool of founders has aged as well, many have shifted their focus to serve the potentially procreating. As a result, when my husband and I decided to embark on the journey to parenthood, we found a new landscape of apps, services, products to make getting pregnant, staying pregnant, and becoming parents as seamless as possible.

As I’ve gone through this pregnancy, I’ve chronicled all the tools, tricks, devices and services that we’ve used.  We’ve been incredibly fortunate - we conceived easily, had a low-risk pregnancy resulting in a healthy baby, received the best medical care through insurance, and are in a position where I can take maternity leave. We recognize that this is not the case for everyone, so this series reflects only one couple’s perspective on the journey to baby.

OMG, BFP*!

Deciding to start “trying” is quite a mental switch.  All of a sudden you go from having spent the last 10+ years of your life trying desperately not to become a parent to becoming hyper-focused on your reproductive activity. Depending on your proactiveness, this process can start well before you decide to start trying. For those who may be a couple years out from parenthood there are a range of new at-home fertility tests for both men and women. Men can take what TechCrunch recently called a “sperm health selfie” (oy)  through companies like Yo and Trak. Women can check their ovarian reserves through Modern Fertility, EverlyWell and Future Family. And while there has recently been some debate as to the value of these tests as an indicator of future success, the movement towards giving people information on their reproductive health more regularly helps start the conversation about fertility - for both genders - at an earlier stage.  There are also more specialty tests, like Dot Lab’s endometriosis test, to help identify conditions that may impact fertility.

If you take the tests and decide that you want to take steps like proactively freezing your eggs, there are start-ups for that too (Prelude Fertility and Progyny, as well as local boutique clinics and larger private equity-owned groups). There are also companies like Carrot who will not only help you freeze your eggs but get your tech employer to pay for it. And there are a growing set of online resources, like FertilityIQ, to help you navigate the process. 

For couples who are actively attempting to conceive, physicians do not generally recommend such testing until six months to a year of trying. Instead, our only pre-baby tests were from Counsyl, which helps Ashkenazi Jews like my husband and I ensure we did not come from the same shtetl.  Most of our focus was instead on the best way to track the all-important, slightly mysterious ovulation cycle. There are no shortage of apps to help you understand your cycle (Flo, Clue, Eve by Glow, Period Tracker, Natural Cycle) and help you get pregnant (those as well as Glow, Ovia). Typically, they have you chart, record your basal body temperature (perhaps through a bluetooth-enabled thermometer like Kinsa), test your levels of an ovulation-related hormone through a urine test, and even check your cervical muscus. After a couple of weeks of this morning routine, we switched to using the Ava bracelet, which is basically a fitbit for fertility that tracks a similar set of biometrics to predict your fertile window. Within a couple of months, our Ava was retired (they have since launched a pregnancy options and are adding metrics to make it more useful during those nine months) and we were on our way. 

Still, one part of the process has not been disrupted yet.  We still found out about our BFP (big fat positive, in Mommyboard speak) by peeing on a stick, even if it arrived through Amazon Prime. (Of course, in the month or so since I wrote this, Lia launched a flushable pregnancy test).

Interested? Stay tuned for Part 2: Information and Appointment Overload in the First Trimester

A Guide to Finding a Mental Health Provider

Tell people that you work in mental health, and odds are they’ll want to tell you how difficult it is to find care.  While we’ve made great strides in reducing the stigma around asking for help, getting it can still be difficult.  I’ve pulled together the guide below, based on my personal and professional experience, to hopefully make it a little bit easier.  

(Note: This guide is primarily for people who are not in acute crisis and who are looking for routine care for mild-moderate depression and/or anxiety. If you or a loved one are in crisis and in need of help, please call 9-1-1, go to the ER, or reach out to your local mental health crisis line for support.)

Finding a Provider Through Traditional Channels

The first question is always what type of care is the best fit - medication, therapy or both? A good primary care doctor or your insurance company’s assessment nurses can help you figure this out. The general rule of thumb is that only MDs and some Nurse Practitioners can prescribe medication, while all licenses can provide therapy.  A couple of other things to consider

  • For medication, in some cases your PCP may be versed in prescribing medication for mild-moderate anxiety and depression. If not, you will need to see a psychiatrist.
  • For Therapy, it’s worth understanding the difference between different levels of providers. Social Workers, (LCSWs or MSWs), Other Master’s Level Clinicians (MFTs, MSs), and Psychologists (PhDs or PsyDs) all provide therapy, but with different education - for instance, research vs. clinical vs. community focus - and often at different price points. What’s most important is to find someone whose expertise is right for you.
  • It’s also important as to what school of thought your provider belongs. Current therapy practice has moved away from Freudian talk theory and towards more evidence-based practices like Dialectical Behavioral Therapy (DBT) and Cognitive Behavioral Therapy (CBT). CBT in particular is a good approach for people struggling with mild-moderate anxiety and depression. It is skills-based and helps you develop tools that will support you as you step down your level of care.

Once you have a sense of what you want, or if you need to talk to someone to figure it out, you can use your Employee Assistance Program (EAP) benefit, if you have one, particularly for therapy. Through these EAP programs, many employers offer short term counseling, either telephonically or in-person. If you feel you need something more on-going, it's worth asking whether your EAP network is the same as your insurance network, and if they can help you find a therapist who takes your insurance.

You can also work through your insurance to see if they can help you find someone in-network (meaning contracted to provide services at a reimbursed rate). While it used to be that insurance companies would give you three names and send you on your way when asked for referrals, a renewed emphasis on accurate provider directories and improved customer service means that many plans are trying to better facilitate appointments. Tools like Amino or ZocDoc can also provide a sense of what providers are in your area. Your employer or insurer may offer a telehealth benefit (through a larger provider like American Well or a smaller dedicated mental health player) or other tools to help you (mindfulness programs like Headspace or coaching programs like Joyable or Lantern).

In some cases, you may choose to go the private pay route, especially in major urban areas, where up to 55% of providers may not take insurance. The downside is that you will find out-of-network providers charging hefty out of pocket fees that might be 2-3x the rate at which your insurance would reimburse them. Keep in mind that if you do then submit a superbill (summary of your visits designed for you to submit) to your insurance company (using an app like Better), most insurance companies will then pay you a percentage of their contracted rate for that service, not the rate you paid. If you are looking for private pay, word of mouth or recommendations are often a good route to find someone.

Newer Provider Identification Models

One of the more promising models in the digital mental health space is the rise of in-person and virtual providers and provider networks who aim to come in at a middle price point between an in-network and out-of-network provider.  Some of the more interesting/evidence-based that are available directly to consumers include the companies highlighted below. There are many other newer offerings, some of which may only be available through your employer.

  • Maven Clinic:  Maven is a virtual platform focused on women’s health. They offer online appointments with a variety of different appointment types, including therapists. They are particularly good for perinatal mental health needs
  • Kip: While only available in San Francisco at this point, Kip pairs a curated network of therapists with a robust platform for tracking mood and homework between visits.
  • Two Chairs: Another SF-only for now offering, Two Chairs is trying to be the One Medical of therapy - offering a concierge-like on-site therapy experience.
  • Ginger.io (disclosure - I used to work there and have an equity position): Originally a machine-learning company, Ginger.io has reimagined itself as a virtual mental health clinic. For $129-$349/month, you can buy a package ranging from text-based coaching to monthly video medication management appointments.

Final thoughts

While finding care can be overwhelming, the good news is that there are many people, from the biggest insurers to the smallest start-ups, working to make it more accessible. This is good news for the industry, and for everyone in need of help. These services can also help you make sure that the provider you find is a good fit for you - it is okay to have to try a couple of people before you find someone who fits. The most important thing is that care helps you move towards recovery in a sustainable way.

Do you have other tips or tricks on finding care? Companies I missed? Please let me know.

The Middle Class and the Middle Gap

The New York Times had a very interesting article this week about America's greying middle class. It posited that seniors between 65-74 were doing surprisingly well in terms of being able to afford comfortable lives.  Many are working, and finding income and engagement as well. While spending on healthcare has increased in the 65-74 population, it has increased significantly more on things like entertainment and booze. It's a great, cheery collection of anecdotes in a sea of disheartening economic stories.

The article does not, however, go into what happens when these seniors age past 74. It does not explore the challenges of getting older and/or the costs of a catastrophic event that requires expensive medical and home care. Median income has risen, albeit not as much, in the 75+ population, but so has average life expectancy - and long-term care costs

Above age 75, healthcare and long-term care costs may push many of these seniors from being middle class to being part of the "middle gap." The "middle gap" is the large population of people who are too well-off to qualify for the extensive benefits of the government safety net, but who may not have high enough income or savings to afford private-pay, people-intensive care if they outlive their nest egg. As our conversation around aging continues to emphasize the importance of honoring and engaging our elders, we are increasingly trying to keep them a vital part of our communities by empowering them to remain in their homes or in independent living as long as possible. However, the cost of long-term supports and services may mean that the golden years of today's greying middle class may not be quite as comfortable as their current economic comfort suggests.

As I think about where innovation could do the most in the aging-in-place space, this is where I'm most excited. What are the products that allow people to afford needed services sustainably? How do you bring technology-enabled solutions into the mix so that they support our elders and their caregivers, without placing undue burden or dehumanizing them. The companies that answer that question, and allow the middle class to navigate the "middle gap" have a bright future ahead of them.

Where do you see opportunity in this space? Who seems to be doing this well today?

There’s a Coach for That

Inspiring people to change behavior, particularly when it comes to their health, is still a huge challenge.  After years of throwing technology at the problem, the digital health ecosystem has come full circle. We are now emphasizing relationships, not information, as the key to change.  The technology-enabled 1-on-1, whether with a peer, trained professional, nurse, clinician or friend, is becoming a key part of mHealth offerings. 

In many cases, this relationship-based service is labeled "Coaching." But what coaching actually means is very company-specific.  Having talked to a number of different coaching Team Leads and others in the industry, here's my understanding of what "coaching" can mean. 

Coaching for behavior change

Most common in consumer-facing apps, coaching for behavior change supplements a consumer-facing tool, generally designed to collect information (e.g., a food diary) and/or deliver content (e.g., online therapy). These programs are about engagement and accountability. Someone else is monitoring my progress, making sure I'm interacting, and cheering me on. 

When it works, it can be a great user experience. I've been using Rise, an nutrition app that has a dietitian monitor my photo food diary for the past few weeks. I find that my coach's assessments and suggestions for improvement keep me engaged. And, as I'm not the only one liking these interactions, a number of healthcare startups that use a B2B2C model are also starting to incorporate coaching as an intervention into their products. Mental health startup Big White Wall is a great example, as they've added a LiveTherapy program for their corporate clients.

The big questions here are who can be a coach, what qualification is required, and when does coaching become medical care? I'm using Rise to better manage my diet, and hopefully achieve some benefits around fitness and energy. Does my coach need to be a registered dietitian, or could she be someone who's gone through a training program, or done a good job with her own health? What if I was pre-diabetic, and weight loss was a medical imperative? Omada, an online version of the group-based Diabetes Prevention Program, does not require a professional health background for their coaches and is still seeing great results in their clinical trials

A parallel exists in the mental health space, where LanternJoyable, and others are now pairing coaching via phone or text with Cognitive Behavioral Therapy (CBT) courses. It's a different model than 7 Cups of Tea, which is also coaching but offers help (not therapy) through peer coaches described as listeners. While all of these models rely on relationships to help individuals who feel in need of connection, there need to be distinctions between who is able to provide what.  Licensing and reimbursement guidelines will have to evolve to reflect the many places people look for care.

Concierge as Coaching

Another example of the reintroduction of the personal relationship back into the consumer healthcare experience is the idea of coach as concierge to help you navigate the healthcare system to get the care you need. Better's Personal Health Assistants are a great example, as they focus on helping people with the logistics part of receiving care. This subscription service is coaching for insurance and appointment scheduling - the stuff that gets in the way.

The idea isn't new - case managers, patient navigators, social workers and others have been playing versions of this role throughout the health care system for years. The question is whether consumers will pay for this as a standalone service. It may become something that is wrapped into other coaching products, or that is picked up by third parties.

Coaching the Clinician

Consumers are not the only ones receiving help in navigating a complex health care system. Startups doing panel management have found that an " air traffic controller" or "triage manager" can vastly improve the efficacy of an app + dashboard platform. These people identify patients in need and "coach" busy clinical staff on where to intervene. They help nudge physicians, therapists and others to change their behavior to better use these platforms. In a recent interview, Dr. John Moore of Twine Health described how their solution included a coach/care coordinator who sits between clinician and patient. At Ginger.io, we found that more time coaching our partners and matching our notifications to work flows improved the effective use of our information.

Defined care management roles do have precedent in less technology-dependent care models. A recent study out of Minnesota, building on the work of the DIAMOND and IMPACT trials, found that having strong care management and a care manager role that was well defined improved the overall outcomes for the collaborative care efforts. As digital health tools become more accepted enablers for care, it will be interesting to see how roles evolve and adapt.

Does my definition and taxonomy of coaching resonate? How is your startup using relationships to drive behavior change?

Yes, your MBA can be an asset at a young start-up

On a recent networking call, someone called me out for referencing "the handicap of a MBA" in a previous blog post. As a fellow MBA looking to get into digital health, she was curious as to what I meant — and how I’d seen people overcome a perceived disadvantage. 

In my experience of early-stage enterprise start-ups, MBA roles have generally fallen into four categories. B2C start-ups or later-stage companies may offer more diverse opportunities, especially in businesses that rely heavily on DTC marketing or supply chains. And of course, the best way to learn what might be of interest to you is to talk to people in these types of roles about what they do all day, and find what sounds exciting.

Product

Everyone wants to drive product, as it's often the heart of most tech companies strategy and direction. “Product Management” is one of those terms that means different things at different organizations. At some companies, it’s product strategy, setting the vision based on market and company feedback. At other companies, it is a much more technical role, focused on specs, roadmaps, and working closely with the engineering team. For MBAs with a technical background, both definitions can be a great fit. For those of us with a liberal arts background , however, the latter role can be a much more challenging one to get, especially at a smaller company. If you’re really passionate about Product Management, starting at a bigger organization with a strong training program may be a better first step than going to the learn-on-the-job environment of a Series A or Series B start up.

Sales/Business Development/Business Operations

What Sales or Business Development means at an enterprise start-up is depends greatly on two things: where that start-up is on the sales learning curve , and whether product strategy is driven by the commercial or product org.

For a seed or Series A start up, sales and BD are often the same function. The focus is on early partnerships that are as much about finding product-market fit as securing revenue. For later-stage start-ups that are moving up the curve, sales functions begin to grow and fit the traditional model, while BD becomes a separate team that drive partnerships  — and occasionally product strategy.

Most MBAs I talk to are most excited about BD roles placing them at the center of product strategy. Unfortunately, these roles are narwhals (I would say unicorns, but that term now means something else). They do exist, but often require luck or years in the trenches as an early employee. More traditional BD or strategy roles are still an option, but generally at later-stage start-ups. And while most MBAs seem to look down on sales (and most b-schools don’t really teach it), I’m a big fan of learning how to sell and how the sales process works. Understanding how to write a SOW (scope of work) and get it signed is something that will serve you well as CEO of your own company (because that’s what you're gunning for, right?).

One other function of note is the rise of Sales Operations/Sales Enablement teams to support Cold Calling 2.0. While this function sometimes overlaps with Product or Enterprise Marketing, I’ve seen a number of MBAs go this route recently. Its a good way to be part of a commercial organization and build a team without carrying a quota.

For consumer start-ups, BD is usually much more of a partnership role, and is much closer to the traditional idea of business development as responsible for new and adjacent products and arrangements.  If you’re looking to develop these types of skills, as opposed to more direct sales skills, this can be a good fit.

Marketing

Often overlapping with sales, marketing roles, particularly quantitative marketing roles, can also be a good fit for MBAs. In organizations where marketing and product marketing are not yet separated, being able to work through market understanding and product positioning, and then map it to brand, product and sales collateral is a valuable skill. Bringing a quantitative skill set to things like pricing, or running a series of campaigns across various social media can also be a meaty role to own.  Again, the biggest thing is understanding what marketing means for that company at that stage, and how that role could grow.

Account/Implementation Management

The final place where Ive seen MBAs come in and make a difference, especially if theyre strong in organizational behavior and execution, is across account implementation and management. For many enterprise startups, getting the contract across the finish line is only half of driving uptake and revenue. Getting people, be they sales reps, clinicians, educators, or whomever else the end user may be to actually use the product daily usually falls to the account management team. These entrepreneurial folks, through a mix of charm, cajoling and empathy, are what make or break early customers.

On small teams, implementation and on-going management are often rolled into one (sometimes with customer support as well).  As the team grows, these types of roles often allow early employees to build a team and/or focus on one part of the client services journey.

What do you think? Where have you seen MBAs make a difference in early-stage start-ups?

 

My #healthcare, #healthIT, #digitalhealth reading list

Over the past few weeks, a number of people have asked me for my healthcare reading list. During coffee chats, JP Morgan happy hours, and calls with others looking to move into digital health, one of the most common themes is how to stay informed and up-to-date in a world of content overload.  My approach, which I've summarized below, is the result of years of dedicated reading. Whether you’re new to the industry or just looking for more sources, I hope it’s a good start.

First things first

Find a tool and a time that work for you. Since the demise of Google Reader, I swear by Feedly, which lets you group blogs by category and scroll through headlines. I generally read quickly, and email anything I want to revisit later to myself. Other folks use Instapaper to store or Flipboard to read content, and it feels like there’s a new reading app every day.

I supplement Feedly with a bunch of email newsletters. There’s some overlap, but it helps make sure I don’t miss key trends.

Start with a general healthcare primer

For my everyday update on what’s going in healthcare, I read the following:

Focus in

I'm currently part of a company building a digital mental health solution. So I’ve really focused in on the digital health and mental health blogs.  For digital health, I read:

For policy, I subscribe to a bunch of newsletters:

For mental health, I’ve learned a ton from Behavioral Healthcare Magazine. I also use Twitter and LinkedIn to find out what’s trending in the behavioral health industry.

Don’t forget the mainstream press

Finally, I make sure to scan the NY Times, Wall Street Journal, Washington Post, Forbes and Fast Company, as well as online-only sources like TechCrunch, VentureBeat, Xconomy, and Quartz.  As healthcare, digital health and mental health have become a much hotter topic, it’s important to understand how people who are not in our bubble are learning about and reacting to relevant news.

What’s your list? What did I miss? Any sources or tips for staying informed?

Two Years, Three Lessons

This past summer marked my two year start up anniversary.  As I was reflecting back on what I often refer to as "years 3 and 4 of business school," I wanted to highlight three lessons learned.

Saying No is as Important as saying Yes

When I started as an eager-to-prove-myself generalist — with the handicap of a MBA in a highly technical organization — it felt like the correct answer to every idle thought about things that would be good for the team to do was "I'll do it." You're at a start up, you're supposed to work hard and wear lots of hats, so why not keep taking on more?

This approach, however, can lead to a level of good performance that does not allow you to be truly great. It can impede the development of a skillset that will allow you to specialize as a company scales. I've had to learn which responsibilities to take on and which to turn down. I've also figured out when to pass on something I've been doing to someone else, often hiring someone to backfill a role I'd been playing. Doing so has given me the space to focus in on the couple (okay, five) things I love doing and can be truly great at, while also helping the company grow.

Similarly, as a young company, it can feel uncomfortable to turn down any partnership opportunities when you're still struggling to build your customer base beyond the first few early adopters. Many cycles can be spent talking to big companies that are thinking about outsourcing innovation, qualifying leads who are asking for something completely different, or just trying to make that one deal work. There are cases where you make the commitment because the payoff is worth is — marquee customers or product-making deals. But there are also deals where you're better off saying no, not right now, and keeping the relationship warm.

You can't get an answer if you don't make the ask

Rejection is scary. Even scarier is the idea that it was something you did that directly led to rejection, especially in a sales or partnership role. I found that I was much better at making bold asks on my own behalf (e.g., intros during the job search) than on the behalf of my company, where I had responsibility for more than myself.  It may also be consulting training, where having good "client hands" is seen as a mark of senior staff, and analysts often defer.

At first, the thought of rejection could hold me back from the smallest ask — product feedback from a potential partner who you want to make a good impression on — to big ones — could you sign by the end of the month? It took a lot of courage to send those first asks and to train myself to be more upfront about what I wanted or needed from partners. However, once I starting being more direct and bold in my requests, I saw how often they were granted. I also saw that even when they weren't, the outcome was still usually positive. My confidence grew, and my — and our — success did as well.

Jane Austen was wrong — it's okay to talk about money

It's a truth universally acknowledged that if you are a start up building a product, at some point you are going to have to ask someone to pay for it. There is an art to the pricing dance — too early and a potential client walks away with sticker shock, too late and you may wind up investing time in a partnership that your client can't afford.  Still, it's okay to be upfront about your pricing model — or flexibility in developing one.  When you've demonstrated a real value from your product, the pricing discussion should flow naturally.

It can be awkward at first, especially if you're new to identifying pockets of spend or understanding budget cycles. Still, it's important to make the ask, be clear in your approach and stand firm where needed. I've built some of my strongest relationships where both partners have financial skin in the game, and we've been able to drive value together.

What is on your list of start up lessons learned? What should I expect to learn in Year 3?

From Consulting to Startups

As a consultant out of undergrad, every winter a spate of analysts would have Thursday doctor's appointments and Friday sick days. The diagnosis? PE interview-itis. 

These days, that mysterious two-day absence is as likely to be from flying out to San Francisco for startup interviews as it is from taking the train to Greenwich. As someone who made the transition from consulting to tech (via a b-school detour), I've spent a lot of time thinking about how the two compare. Below, I've outlined my experience.

What's constant:

  • Focus on learning

We used to joke that our consulting firm was full of "insecure overachievers" who were constantly working to learn more and deliver an impact.  The same focus on learning and impact is common among my colleagues and startup friends, although it's often much more self-motivated. Professional development now means online courses and General Assembly, not training sessions and Friday morning excel boot camps.

  • A balance between team and independence 

I always liked the consulting team set up. We often ran four or five work streams for a given project. Owning one of those work streams let me independently run a part of the problem, while still being part of a larger effort. The same thing is true of startups, especially small ones.  While everyone has the things for which they are individually responsible, only when those pieces fit together do we all succeed.

  • The stress — and need to take care of yourself

Consulting is stressful — there are tight timelines, demanding clients, and (usually) clear deliverables.  Startups are stressful as well, albeit often for opposite reasons. Timelines slip, you may not have clients, and the deliverables shift.  Both environments, for better or for worse, require a willingness to be a duck at times — calm above the surface of the water, paddling furiously underneath.  And in both environments, figuring out how to take care of yourself is essential.  For me, that means exercise, reading, and throwing dinner parties. Knowing those outlets and making sure you have time for them is non-negotiable.

What's changed

  • Your colleagues are much more diverse — and that's a good thing

In consulting, basic training bootcamps teach everyone to approach a problem, communicate and give feedback in the same way.  At a startup, not so much. Engineers, designers, data scientists, product people, marketers — everyone brings a unique perspective. While this makes for a stronger team, it can be an adjustment. I've had to strengthen my ability to see things from other perspectives and adapt my communication style. But I am a better colleague, and a better leader, for the experience.

  • Your path is not set — which makes it more open

The org chart for many startups, if it exists at all, is scrawled on a  napkin or stored in a half-forgotten google doc.  When you join an early stage "rocket ship"  (and if you don't think it's one, don't join), you join with the expectation that you and your role will grow with the company. But what it grows into can be unclear.  For those coming from a world of set roles and promotion timelines, coming to terms with that uncertainty can be tough.  The flipside, however, is that it is much easier to try out different roles, either by taking on short term projects or by making a bigger change.  Still, be ready to sometimes not know what the next step is, and to be able to self-motivate without that clarity.

  • 80/20 isn't just a catchphrase, but a reality

In consulting, everyone talked about the 80/20 answer, but I often felt the need to go to 90 to fulfill client expectations.  At a startup, 60% is often the 90% answer, especially if you're juggling multiple roles or rushing to get back to a client or investor in a timely fashion. Often, because you are scoping your own deliverables and goals, you have to rely on your own instinct — there is no one to tell you "enough" or "do a bit more."  Developing that sense of what 80/20 looks like is an important skill.

What did I miss? What else have you found if you've made the transition from consulting to startups?

Nota bene: if you're curious about the difference between those finance jobs and consulting, there's always this informative video.

Doubling down

In the midst of an A-for-effort "crafternoon"  this weekend, a friend observed that she was grateful we lived in a specialization economy. She reveled in being able to go out and buy things (in this case, kombucha) instead of having to make it herself.  While San Francisco's DIY culture can obscure specialization, (doesn't everyone have a mother bubbling away on a top shelf?) there is virtue in knowing what you're good at. 

The beta launch of this personal website started a similar conversation.  A colleague's first question upon seeing it was "What's Squarespace?"  
My response? "WordPress for idiots." 

My flip response isn't fair to Squarespace, which has built a product to fill a need — easy websites for people who don't know how to code. Nor is it fair to the people who use it. But his question did prompt a sense of guilt. I'd only gotten through three sessions of CSS/HTML on Codeacademy. The best way to learn to code is to give yourself a project or goal. Why wasn't I using this blog as a spur to learn a new skill?

Because I wasn't blogging to pick up a new skill. Rather, I was blogging because I wanted to improve skills I already had. I wanted to practice analyzing information and crafting it into a well-written story. In a culture of MOOCS and GA and everyone learning to code, "learning" often applies only to developing an ability from scratch. However, my goals are more around getting better at the things that I do well.

For me, personal growth requires a mix of learning both the old and the new.  It's not enough to just identify and address the gaps where learning something new gets you closer to your goals. You have to double down on your "super powers."  And when I think about my goals for this blog, they all relate to keeping my super powers sharp. So while Squarespace may be the easy way out on the coding question, setting up a tool that pushes me to write still means I'll continue to learn and grow. 

And I can always restart Codeacademy tomorrow.

What do you think? How do you define learning, and where do you spend your time?