Shiv Rao, MD

I have interviewed 1,000s of the world's best founders over the past decade. Few have impressed me like @ShivdevRao at @AbridgeHQ. He navigated a brutal 5-year wilderness before exploding into one of the most dominant forces in vertical AI. Today, Abridge is a $5.3BN powerhouse. I sat down with Shiv to unpack exactly how he did it and condensed my notes below: 🚀 6 Lessons on Building a $5.3B Vertical AI Juggernaut 1. Survive Long Enough for Market Timing to Catch Up: Abridge spent 5 years in the "wilderness" before hitting a tidal wave of adoption. When you have an absolute true north thesis, your primary job in the early days is simple: stay standing and don’t die. You must be alive when the sky finally opens up. 2. Pivot the Product, Never the Core Thesis: Shiv was willing to pivot on features, go-to-market strategies, and business models. But he refused to budge on his core thesis that healthcare is ultimately powered by the spoken human signal. Die on the hill of your thesis; adapt everything else. 3. Target the Concentration of Scale Early: A massive trap for healthcare and enterprise founders is staying down-market too long for "fast feedback loops". In the US, the vast majority of clinicians are concentrated within large, integrated delivery networks. Time your "YOLO shot" to go up-market the moment the market inflects. Single biggest advice to founders on when to go up market @bhalligan @dharmesh? 4. Own Your Stack to Protect Your P&L and UX: While many AI startups rely entirely on frontier systems, 40% of Abridge's model outputs are generated by in-house models. Milliseconds matter in high-stakes enterprise workflows. Building your own models gives you insane performance gains, lower latency, and ultimate control over your P&L. When should you vs should you not build your own model @matanSF @MaxJunestrand @antonosika? 5. Don't Fight Foundation Models—Counter-Position Instead If you try to fight the frontier model giants directly, you've already lost. You win by going millions of miles deep into regulated industries with proprietary datasets and workflows they can't easily replicate. Find ways to coexist and leverage their tailwinds. Reminds me of what @bradlightcap said on his 20VC. 6. Move Toward the "Flat Company" Era: With the explosion of AI agents and advanced tooling, the traditional management layer is compressing. Shiv’s latest idealistic shift is building a hyper-flat organization: fewer managers, and highly leverageable "Super ICs" who can move in lockstep and cover massive surface area. (link in comments)

.@tobi removed all the Norman doors from Shopify’s offices because he couldn’t have excellent people surrounded by bad design. Ramp Cofounder @eglyman says he learned the same lesson by studying Breville toasters: “ If you care about design, you should buy a Breville toaster.” “ One of the big problems in a lot of B2B software is: it starts out clean and elegant. There's a bunch of businesses who love the product and they start serving more customers and have more requirements and more ideas.” “Before you know it, you end up with these disasters of B2B softwares which require a PhD to learn how to use.” “ If you were to go ask people, ‘What do you want in a toaster or in a microwave?’ They might say I like toast but sometimes I want to reheat pizza. I should have a ‘reheat frozen pizza’ mode. Or maybe you're cooking stuff and want it to be more like an oven, or you want to make popcorn and it's a toaster/microwave and all these things.” “Before you know it, you end up with these toasters filled with buttons and buttons and knobs and dials.” “That is literally asking customers what they want and building exactly that.” “ if you watch people toast things, what they actually do falls into two categories: you hit start and either you've undercooked the toast and need to put it back in, or you've overdone it and have to start over.” “If you look at the [Breville] there are only a few buttons. One of the four buttons is called ‘A Bit More.’” “ No one would ask you for ‘A Bit More.’ They just want the perfect level of toast and it's hard to know that, so they built that in.”

Abridge: 100M+ medical conversations, real-time prior auth, and the clinical intelligence layer latent.space/p/abridge @AbridgeHQ is building the clinical intelligence layer for healthcare. In this episode, Janie Lee and @c_asawa explain why ambient documentation was only the first wedge, how Abridge is turning patient conversations into real-time clinical decision support, why healthcare may become one of AI’s most important proving grounds, and how 100M+ medical conversations, specialty-specific evals, and deep EHR integrations create a moat for AI-native healthcare.