Once You Are Inside: 5 Things Clinician Leaders Need to Know about Startups with Helen Tanner, PA-C, MPH (Solo Mini-Series, Part 2 of 2)
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Once You Are Inside: 5 Things Clinician Leaders Need to Know about Startups
In part two of this two-part solo mini series, host and startup leader Helen Tanner walks through the five things every clinician leader needs to navigate once they are inside a healthcare startup: the first weeks, the first six months, and the first year.
She explains how to know whether you were hired to build the first version or to learn an existing machine, how to build clinical infrastructure that matches the company's stage rather than the health system you came from, why your license is a separate entity from the company and what protecting it actually requires, how to navigate the tension between the mission and the money that lives inside every healthcare startup, and why maintaining your professional identity outside the company is the smartest career protection there is.
For each of the five topics, Helen shares a practical next step, a question to ask, or a resource to help you lead with your eyes open.
Together with part one, this completes the full list: 10 Things Every Clinician Should Know Before and After Joining a Startup. You can get the whole list, with every question and resource from both episodes in one place, in The Early Hires Clinician Startup Field Guide, linked below.
Must-Hear Insights and Key Moments
Whether you learn first or build first depends on when you arrive: a founding hire at seed has nothing to listen to, while a Series B inheritor needs a compressed listening window with a date on it.
The cost of playing the wrong job is the two things a startup never gives back: runway and credibility. Startups form opinions about people in weeks, not years.
A seed-stage company does not need a forty-page policy manual. It needs one page that is actually true and actually followed, with a version number and a review date.
There is a non-negotiable clinical floor at every stage: verified licensure, confirmed malpractice, collaborating agreements, a documentation standard, and a safety reporting path. Product companies have their own version of that floor.
The company's risk tolerance is not your risk tolerance. Software iterates; your license record follows you for the rest of your career, so read the malpractice policy yourself and keep personal copies of everything you sign.
Every healthcare startup lives with tension between the mission and the money, and the clinical leader sits at the exact point where they meet. Watch what actually happens when you raise a safety concern.
Most venture-backed companies never return the money invested in them. Keeping a clinical foothold, active licenses, a current CV, and a network outside the walls is planning, not disloyalty.
Words of Wisdom: Standout Quotes from This Episode
“ Your title is real on day one. Your authority is earned separately.” - Helen Tanner
“Match your speed to your stage. If you are first, start building. If you inherit something that runs, diagnose before you treat. Both are moving fast. They just start in different places.” - Helen Tanner
“Build the guardrails the stage requires, and put a version number on everything else.” - Helen Tanner
“The company is insured. Make sure you are. Your license will outlive every job you ever hold, so protect it like the asset it is.” - Helen Tanner
“The company is a chapter. Your career is the book. Keep writing the book.” - Helen Tanner
Mentioned in the episode:
Get The Early Hires Clinician Startup Field Guide: 10 Things Every Clinician Should Know Before and After Joining a Startup. It brings together every question, number, and resource from both episodes of this series in one place. Sign up at www.theearlyhires.com and the guide comes straight to your inbox. You will also be signed up for The Early Hires monthly newsletter.
Dig Your Well Before You Are Thirsty by Harvey Mackay
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Episode Transcript:
Note: We use AI transcription so there may be some inaccuracies
Helen Tanner: Welcome to The Early Hires, the podcast for clinicians and startups. I'm your host, Helen Tanner. This is a show for early clinical operators working alongside founders to build the next generation of healthcare companies. Every episode is designed to help you feel more understood in your role, clearer about your influence, and more confident in how you show up inside a growing company. If you're a clinician working inside a startup, The Early Hires is for you.
Welcome back to The Early Hires. This is part two of the solo mini-series, 10 things every clinician leader needs to know before and after joining a startup. Last episode, part one, the five things to work through before you sign while you still have leverage. Know the stage, know the board and ownership. Get equity-literate, translate your credentials, and pin down the clinical-versus-administrative split.
If you have not heard it yet, it stands on its own, so go back to it. But you do not need it to follow today.
Today, the five things that matter once you are inside. The first weeks. The first six months. The first year.
The format is the same. For each one, I am going to name the thing. Then I am going to give you something to do about it. A next step, a question to ask, or a resource to use. Same caveat as last time: I am focusing on leadership and management roles. But even if you are not in leadership, this is the inner workings of the company you now work for, and it is worth knowing.
Let's get into it.
ITEM SIX: KNOW WHICH JOB YOU HAVE. LEARN FIRST, OR START BUILDING. (1:45)
Number six. Know which job you have. Are you here to learn an existing machine, or to build the first one?
The classic corporate advice says learn before you fix. Take ninety days. Listen, observe, then act. And tech has a famous answer to that advice: move fast and break things. That was Facebook's internal motto, coined by Mark Zuckerberg, and it shaped the culture of nearly every startup that came after. Facebook eventually retired the phrase, but the DNA stuck. Startups move fast. All of them. Nobody is handing you a ninety day listening tour.
So which is it? It depends on when you arrive, and what you were hired to do.
If you are brought in early to build, the founding clinical hire at pre-seed or seed, there is nothing to learn before fixing, because there is nothing built yet. You are round one. A listening period does not make sense when there is nothing to listen to. The company hired you to start. Your version of learning looks different: research, best practice, start. Pull the published standards. Call the colleagues who have built this at other startups. Adapt what works, and begin. Version one will get rebuilt, and we will talk about that in item seven. But waiting for perfect information while the company burns runway is not caution. It is missing the job you were hired to do.
If you join later, Series B, Series C, a clinical operation that already runs, now the learn-first advice starts to apply, just on startup time. There is a machine already running. The workflow that looks broken may be the third version of something that failed twice for reasons nobody wrote down. You likely have some breathing room, and honestly the necessity, to understand it before you change it. But compressed. Weeks, not a quarter.
Why does this matter to sort out early? Because the cost of playing the wrong job is the two things a startup never gives back: runway and credibility. Spend a quarter listening when you were hired to build, and the founders start making clinical decisions without you, because decisions do not wait. Come in swinging at something that already runs, and you break workflows that were holding more weight than you knew, in front of the team that built them. Either way, six months in, you are being measured against a job you were not doing. And startups form opinions about people in weeks, not years.
And in both cases, one thing is the same. Your title is real on day one. Your authority is earned separately. If you are early, you earn it by building something that works. If you join later, you earn it by showing the room you understand the business before you prescribe to it.
Here is what to do about it.
First, have clarity about which job you have. Know the expectations. Hired to build round one, or hired into something that already runs? Most of the friction I have seen comes from playing the wrong one.
If you are the builder: research, best practice, start. Do not wait for permission or perfect information. Timebox the research, days, not months. Then launch version one and label it version one.
If you inherit a running operation: take a compressed listening window and put a date on it. Sit in on sales calls, standups, the investor update. You are learning how the money flows and who actually decides, which, as we covered in part one, is not always the org chart. Before you propose anything, ask one question: what has been tried already? And find the historian, the person who has been there the longest and remembers why everything is the way it is. Buy them coffee.
And in both jobs, set up frequent check ins with whoever you answer to. Your manager, your director, the CEO directly. Weekly at a minimum in the beginning, more often if you can get it. Targets and goals change quickly at this stage, and it can feel like you are chasing a moving target, because you are. That is not a sign something is wrong. It is the stage. Frequent touch bases with a quick priority check keep you and the company on the same page, and they keep you from spending three weeks building the thing that mattered last month.
Either way, keep a running list of everything you see. For the builder, it is your backlog. For the inheritor, it is your roadmap, and by the time you act on it, it comes with context.
The takeaway: match your speed to your stage. If you are first, start building. If you inherit something that runs, diagnose before you treat. Both are moving fast. They just start in different places.
ITEM SEVEN: BUILD CLINICAL INFRASTRUCTURE THAT MATCHES THE STAGE (6:15)
Number seven. Build clinical infrastructure that matches the stage. Not the infrastructure you came from.
And before this sounds like I am repeating item six: they are cousins, but they answer different questions. Six was about timing. When do you act, and how fast, based on the job you were hired into. Seven is about sizing. Once you are building, how much structure does this stage actually need? You can get the timing right and still build the wrong amount. One is the clock. The other is the blueprint.
Most of us come from health systems. So when a startup asks us to stand up clinical operations, the reflex is to rebuild what we knew. A forty page policy manual. Standing committees. A pharmacy and therapeutics structure for a company with eleven employees.
A seed stage company does not need the policy manual from your old health system. It needs one page that is actually true and actually followed. Overbuild and you slow the company down with governance meant for an organization fifty times its size. And worse, people start ignoring the binder, which is more dangerous than not having one.
But it cuts the other way too. If you are at Series B and clinical operations still run on memory and Slack threads, that is not scrappy anymore. That is risk.
So what does the minimum look like? On day one, some things are non negotiable at any stage. Licensure verified. Malpractice confirmed, in writing. Collaborating or supervising agreements in place where your states require them. A documentation standard. And a way for anyone on the clinical team to report a safety concern and know it will be seen. That is the floor. That is the list I would not open the doors without.
Now, everything I just listed assumes you deliver care. So let me give the other version, because plenty of you are at product and digital health companies where no patient is ever seen. The baseline exists there too. It just looks different. It is the evidence behind the product: can you defend, on paper, the clinical claims the website makes? It is a clinical sign off process, so nothing patient facing, content, an algorithm, a triage flow, goes out without a clinician reviewing it. It is the escalation path for the moment a user types chest pain into your chatbot at two in the morning: what happens next, and who decided that? And it is knowing where the regulatory lines are, because the distance between a wellness app and an FDA regulated medical device is shorter than most founders think. If you are the clinical leader at a product company, that is your baseline.
Everything above that baseline gets built in versions. Version one of your quality program might be a spreadsheet where you track incidents and a few key metrics, and one hour a month where you actually review it. That is fine. Put a version number on it and a review date, because you will rebuild it at the next stage.
Here is what to do about it.
Write two lists, and write them early. If you are the builder, this is week one work, before anything launches: must be true today, and can wait. If you inherited a running operation, build the same two lists during your listening window.
Do not invent from scratch. Your professional organizations publish standards. Colleagues at other startups will share templates, and this community is exactly the place to ask. Adapt, credit, and move on.
And every time the company doubles, in headcount, patients, or states, reread what you built. If it still fits, keep it. If it does not, version two.
The takeaway: build the guardrails the stage requires, and put a version number on everything else.
ITEM EIGHT: YOUR LICENSE IS A SEPARATE ENTITY. PROTECT IT ACCORDINGLY. (10:00)
Number eight. And this may be the most important one in this episode. Your license is a separate entity from the company. Protect it accordingly.
The company's risk tolerance is not your risk tolerance. Startups run on speed and iteration. Ship it, learn, fix it next sprint. For software, that works. Your license does not iterate. A state board does not grade on innovation. And if the company fails, the corporation dissolves. Your license record follows you for the rest of your career.
What does this look like in real life? It looks like being asked to "just sign off" on care delivered in a state where you are not licensed. It looks like a supervising ratio creeping past what your state allows, one hire at a time. It looks like a protocol that quietly stretches past scope of practice because nobody in the room knew where the line was. And remember item four from part one. Most of the time this is not malice. It is a knowledge gap. They may not know. Which means you have to.
Here is what to do about it.
Read your malpractice policy yourself. Not the summary in your offer letter. The policy. Know whether it is occurrence based or claims made. And if it is claims made, ask now, in writing, who pays for tail coverage when you leave. That single question can be worth tens of thousands of dollars.
Consider carrying your own separate malpractice policy in addition to the company coverage. It is not distrust. It is a second parachute, and depending on your role it can be more affordable than you expect.
If you are the decision maker, go further. Get the malpractice carrier and the company attorney in the same conversation, and confirm that you and every clinician under you are properly covered for what the company actually does now. States, modalities, all of it. Coverage that matches the job description from six months ago is not coverage.
And if you are a supervising physician, or you practice with a collaborating physician, get clear in writing on what happens when someone leaves. When will you be notified? Who is the backup, so state requirements stay met on day one and not day ninety? Clinicians have been left out of compliance without knowing it because a departure never reached them.
Keep personal copies of everything you sign. Collaborating agreements, supervision agreements, protocols with your name on them. Company systems disappear when companies do. Your files should not live only in their drive.
When a request touches your scope or your license, respond in writing. Not as a threat. As a record. And I want to give you the actual sentence, because tone matters here: "I want to find a way to do this, and I need it to be within my scope. Let us figure it out together." That sentence protects you and keeps you on the same team.
And know your state boards. Supervision ratios, telehealth across state lines, delegation rules. If you are the senior clinical voice in the room, you are the one who is supposed to know.
One more thing, and this one is for the founders and hiring managers listening. I have watched founders get frustrated at the pushback, at the multitude of questions clinical leaders ask about protection. So let me explain what is underneath those questions. If a clinician is sued, we report it for the rest of our careers. Every credentialing application. Every license renewal. Forever. Even if the case was dismissed. Even if it was a complaint that went nowhere. This is not a hire a lawyer and make it go away problem. It follows us, and it costs us paperwork, explanations, and stress for decades. So if you want a smooth ride working with clinicians at an early stage company, have your ducks in a row. Deeply listen, and cover your clinicians. Make their protection a visible top priority, and you will gain more credibility with your clinical team than any mission statement will buy you.
The takeaway: the company is insured. Make sure you are. Your license will outlive every job you ever hold, so protect it like the asset it is.
ITEM NINE: THE MISSION, THE MONEY, AND THE TENSION BETWEEN THEM (14:15)
Number nine. The mission, the money, and the tension between them.
I want to set this one up carefully, because it is not a warning about bad actors. It is about a tension that is built into every healthcare startup, and that you will not fully see until you are six months in. Maybe a year.
The mission is real. It is probably why you came. It is why I came. And the money is real too. Runway, investors, targets. Every startup lives in the space between those two forces, and as the clinical leader, you live at the exact point where they meet.
That tension shows up in two opposite ways, and the industry has seen plenty of both. You have heard versions of each from guests on this show.
The first is the minimum viable product mantra that never grows up. Minimum viable is a legitimate way to start. It is how startups work, and as we said in item six, if you are early, version one is the job. But medicine is not software. There comes a point where the stage catches up. Real patients, real volume, real complexity. And if minimum viable is still the whole philosophy at that point, that deserves a hard conversation. The floor we talked about in item seven does not scale itself. Somebody has to argue for that investment, and that somebody is usually you.
The second runs the other way. The company spends big early. Builds beautifully, hires generously. Then the market shifts, or the next round comes in smaller than planned, and the layoffs and cutbacks arrive. Quality gets threatened from that side too. Just later, and with less warning.
I do not have a perfect answer for this one. But it comes back to six and seven. Stage matters. The right level of investment in safety, quality, and oversight depends on where the company is. What does not depend on stage is the baseline. There is a foundation that must be met at every stage, and holding that line is a core part of the clinical leader job. Not the fun part. The core part.
And notice how the company carries this tension, because a healthy one carries it with you. Leadership talks about the tradeoffs openly. Funds the floor without a fight. Tells you when money is tight instead of letting you find out. If the mission only gets mentioned when someone is asking you to absorb more with less, notice that too.
Here is what to do about it.
Make your case in operational terms. This is the language skill from part one. Not "my team is drowning." Instead: "safe coverage for this panel is one clinician per this many patients, here is the gap, and here is what it costs to close it." Numbers move these conversations. Feelings, unfairly, usually do not.
Watch what happens when you raise a safety concern. Not what the values slide says. What actually happens. That response tells you which side of this tension your company is really on.
And pay attention to your own sleep. I mean that literally. If the gap between what the company funds and what you believe patients need is costing you sleep too many nights in a row, that is data. It is often the earliest signal you get. And if it goes on long enough, it stops being a culture question and starts becoming a license question. That is item eight, and the two are more connected than they look.
None of this is visible from the interview process. These are the things you learn at month six, at month twelve. Which is exactly why they are in part two.
The takeaway: every healthcare startup lives with tension between the mission and the money. Expect it, because your job is not to make it disappear. Your job is three things. Hold the safety baseline at every stage, no matter what. Speak up for the investment the current stage requires, in numbers. And pay attention when the gap between the two starts costing you sleep, because that signal arrives before any other.
ITEM TEN: MAINTAIN YOUR EXTERNAL PROFESSIONAL IDENTITY. STARTUPS FAIL. (17:00)
Number ten. Maintain your external professional identity.
This is the one nobody wants to say out loud, so let me say it plainly. Most startups do not make it. The majority of venture-backed companies never return the money invested in them. That is not pessimism about your company. That is the base rate of the industry you now work in, and no amount of talent inside the building changes it alone.
You may not be able to control whether the company makes it. You can control whether your career does.
The trap is quiet. The title becomes your identity. The clinical skills age a little each quarter you do not use them. The network shrinks to the company Slack. You stop investing in your own career and professional identity. And then one Tuesday there is a board meeting you were not in, and you are updating a CV you have not touched in two years.
Here is what to do about it.
Five suggestions. Pick the ones that fit your life.
One. Keep a clinical foothold, if you want one. Not everyone wants to keep practicing once they move into leadership, and that is a legitimate choice. But many of us do, and it is one of the easiest job security moves there is. A PRN shift once a month, even once a quarter, keeps your skills current, keeps your resume unambiguous, and holds a door open at very little cost.
Two. Keep every license and certification active, even the ones this job does not use. Renewals are cheap. Reinstatement is not.
Three. Update your CV and LinkedIn once a month. Fifteen minutes. Capture what you built in operational terms, with numbers. Launched a service line in three states. Built a quality program that cut readmissions. You are not being disloyal. You are keeping records, and future you will thank you.
Four. Stay visible outside the walls. One conference, one post, one coffee a month with someone who does not work at your company. NY Times best selling author, business leader, and one of America's most popular and entertaining business speakers, Harvey Mackay, wrote an entire book on this, and the title says it all: Dig Your Well Before You Are Thirsty. The best time to build your network is when you do not need anything from it. So stay visible outside the walls. Your next role will come from that network, not from your current org chart.
Five. Ask the planning question twice a year: if this ended tomorrow, what would I do next? If the answer scares you, that is not a reason to panic. That is your project this month. This is not a warning. It is a planning exercise. Well. Maybe it is a little bit of a warning.
The takeaway: the company is a chapter. Your career is the book. Keep writing the book.
CLOSE (20:15)
Before I wrap the list, one more thing. And it might be the most important thing I say today. After a year inside, breathe. Take a second and realize that almost nobody has done what you are doing. That is the whole point of a startup. It is new. It is innovative. It is trying to close a gap that matters, one the existing system has not managed to close. The work is hard. So hard. And it is also some of the most rewarding work you will ever do. Even if the company folds. Even if you leave. Even if you are laid off, or the company sells. You will have been part of building something, and you will have had a hand in it. Nobody can take that from you.
And everything we covered today, all five items, they are important to work through. They are also normal. The doubts, the questions, the protections, the course corrections. These are standard parts of startup life, not signs that you necessarily chose wrong. Normalizing them matters, because when you know an experience is normal, you ask more. You advocate more. You network more. And you lead stronger.
So that is part two. And that is the full ten.
Once you are inside: learn before you fix with an asterisk. Build to the stage. Protect your license like the separate entity it is. Keep the mission mutual. And keep your professional identity bigger than any one company.
Put the two episodes together and you have guidance. Ten things, front to back.
Startups need us in these rooms. Every item on this list exists so that you walk in any way prepared with your eyes open because a clinician who walks in prepared becomes a better early hire, a stronger leader, and a fiercer advocate for their team and their patients. That is the whole reason this show exists.
The free guide from part one now includes the questions and information from today. Everything in one place. The link is in the show notes and on the Early Hires website. See you next time.
Thanks for listening to The Early Hires. These conversations exist because clinicians like you are doing hard, important work inside growing companies.
If this episode resonated, please share it with a colleague and take a moment to rate the podcast so more clinicians can find The Early Hires. And if you'd like more, visit TheEarlyHires.com for the latest news, resources, and updates for clinicians and startups. I'm Helen Tanner. Thank you for the work you're doing and the voice you bring to it.
