A CEO's primary role differs fundamentally based on company type. In an asset-centric biotech, the CEO must act as a hands-on program manager, micromanaging execution. In a platform company, the CEO must be deeply embedded in the science to predict and leverage the technology's long-term trajectory.

Pfizer's CEO was named a "Best CEO" not for pipeline success but for effectively managing political pressure from the Trump administration. He made deals that appeased the White House on drug pricing without harming shareholder value, highlighting how a modern pharma CEO's job now heavily involves navigating the political landscape.

Experience taught Herb Wagner that great leaders consistently surprise on the upside. He now weights leadership quality far more heavily, assessing CEOs not by interviews or charisma, but by their verifiable track record and through trusted backchannel references who have worked with them directly.

Despite success, founder Kevin Wagstaff felt like an "imposter" as the company scaled beyond $10M ARR. He recognized his strengths were in the early, scrappy "bias to action" phase, not managing a larger organization. He proactively brought in a seasoned CEO better suited for the next stage of growth.

Public companies, beholden to quarterly earnings, often behave like "psychopaths," optimizing for short-term metrics at the expense of customer relationships. In contrast, founder-led or family-owned firms can invest in long-term customer value, leading to more sustainable success.

Astute biotech leaders leverage the tension between public financing and strategic pharma partnerships. When public markets are down, pursue pharma deals as a better source of capital. Conversely, use the threat of a public offering to negotiate more favorable terms in pharma deals, treating them as interchangeable capital sources.

Unlike software startups that can "fail fast" and pivot cheaply, a single biotech clinical program costs tens of millions. This high cost of failure means the industry values experienced founders who have learned from past mistakes, a direct contrast to Silicon Valley's youth-centric culture.

To save money, Rhythm's leadership considered canceling a clinical study because the prevailing scientific logic suggested their drug wouldn't work. The study's unexpected, resounding success became the company's pivotal turning point, highlighting the value of pursuing scientifically contrarian ideas.

High-performing CEOs don't hesitate on talent decisions. One mentor's advice was to act immediately the first time you consider firing someone, as indecision only prolongs the inevitable and harms value creation. This counteracts the common tendency for CEOs to be overly loyal or fear disruption.