In 2006, a year out of my residency in nuclear medicine, I went to a series of job interviews. One of them was with a man who owned a cancer hospital in a small town in Brazil, and he wanted someone to manage his new diagnostic imaging department.
I arrived and he showed me into a room with four walls, a floor, a ceiling, and nothing else.
I asked him which department I was supposed to be managing. He said I was standing in it.
I took the job, which in retrospect is the most consequential decision in this story and at the time felt like the only interesting offer on the table. Over the next six months I wrote the radiation safety procedures, negotiated with equipment vendors, drafted the imaging protocols, hired the staff, trained them, and then went out and sold the service to referring physicians who had no particular reason to send us anything.
None of that is medicine. I had spent eleven years in training and practice learning to read images and treat patients, and here I was arguing with a vendor about service contracts.
Two years later the department had grown enough to be funded for a radionuclide therapy expansion, which I planned and executed. Then a larger clinic in São Paulo asked me to do the same thing for them.
That was the point I understood something about myself that took another decade to act on properly. I was not a doctor who happened to be handling operations. I was an operator who had been trained as a doctor, and the clinical training was the more useful half of the equipment.
What actually transferred
Not the medical knowledge. Almost none of that is relevant to running a business, and people who claim otherwise are usually selling a metaphor.
What transferred was the sequence.
Medicine is unusually strict about the order in which you're permitted to do things. You examine, then you form a differential diagnosis, then you treat. You are not allowed to treat first and see how the patient responds. You are not allowed to skip the examination because the presentation looks familiar, and the times you're most tempted to skip it are exactly the times it matters most, because a confident wrong diagnosis is more dangerous than an uncertain right one.
That discipline is drilled into you for years, with consequences attached, until it stops being a procedure and becomes the way you look at a problem.
Then I walked into business, where almost nobody does this.
The normal sequence in a small business is: decide what you want, then work backward to a plan, then look for numbers that support it. The goal comes first because the goal is the enjoyable part. The examination gets skipped, or done quickly, or done after the decision has effectively been made and is now looking for justification.
I've watched owners set a revenue target for the coming year in under ten seconds and then take three weeks to tell me what last year's monthly margins were. The target was instant. The examination was homework.
That's the whole of what I brought over from medicine, and it's the origin of the method I use now — the TAG method — See the Truth. Implement Actions. Achieve your Goals. Truth is where the business actually is. The goal is where it's going. Actions are the line between two points, and you can't draw a line from a place you haven't located.
The time I skipped my own sequence
I want to be specific about that, because the sequence is easy to describe and I have personally failed to follow it.
In 2011 I started a software company with three partners. We split the equity evenly, four ways, with a portion set aside for an investor. We raised two hundred and fifty thousand dollars. We had genuine enthusiasm, a real market, and no agreement whatsoever about who was responsible for what.
That last part was decided at formation, which is to say it wasn't decided at all. Everyone was excited, nobody wanted to be the person asking uncomfortable questions about deliverables and accountability, and equal shares felt like the fair and frictionless answer. It took about an afternoon.
Six months in, the contribution had become badly uneven, and there was no mechanism to address that, because we had never built one. I was running the company around a full-time clinical director job, getting steadily more overwhelmed, and I responded by hiring contractors to cover the gap. I couldn't evaluate developers, not being one, so I hired expensively and badly.
We closed it in 2013.
For years I described that as a market problem — mobile gaming was brutally competitive and development costs were higher than we'd modeled. Both true, and neither is the diagnosis. The diagnosis is that we set the goal before we examined anything, including ourselves. We decided what we were building and how we'd split it before establishing who could actually do what, how much of their attention we had, and what would happen if someone stopped delivering.
I'd spent five years by then insisting on examination before treatment in a clinical setting. Then I structured a company in an afternoon because asking the hard questions would have spoiled a good mood.
What came after
The pattern of my working life since has been the same job in different settings. In 2009 I did an MBA and started a radiation safety company, which I later sold privately to my partner, who built on the foundation and grew it well beyond where I left it.
In 2015 my family and I sold everything we owned in Brazil and moved to Florida to start a senior home care agency. We put in about a hundred and fifty thousand dollars. It opened its doors that October, and roughly five years later we sold it for seven figures, after a year in which we billed and collected more than a million dollars in services.
That one worked because I ran it the way I'd been trained to run a clinic. Examine the market, examine the economics, examine the staffing model, and only then decide what we were going to do about any of it.
Then four years advising more than fifty owner-operated professional services firms on how to start, manage and grow, which is the same sequence again, applied to other people's businesses instead of my own.
The room is usually emptier than it looks
I've thought about that first room a lot, and what strikes me now isn't the emptiness. It's that the owner knew exactly what he wanted and had no idea what it would take, and he was entirely comfortable with that combination. Most owners are. It's not a character flaw, it's the default condition of running something.
The job I've done ever since, in a hospital, in a home care agency, in a professional services firm, is to walk into the room and find out what's actually there before anyone decides what to build in it.
That's less exciting than a vision. It's also the only part that reliably works.