Fourteen months after the appointment, the company was below revenue plan.
The VP Sales had fifteen years in medical devices. Strong cardiology procurement relationships. The kind of CV that makes a board feel confident. He was working hard. But the commercial model hadn't been built, territories hadn't been designed, and the first sales hire beneath him hadn't been made. The lighthouse account strategy didn't exist.
He was managing the organisation as if it were the large company he'd come from rather than the early-stage one it actually was. Not because he was wrong. Because the brief was wrong. And nobody caught it before the appointment was made, because nobody was positioned to.
The stage is the brief
Commercial hiring in medical devices isn't a linear process. It's a stage-dependent one. The skills, behavioural profile, and leadership style required at each stage of a device company's commercial development are genuinely different. The differences aren't marginal. They're structural.
A candidate who is exactly right at one stage can be exactly wrong at the next. The most expensive mis-hires in this market aren't the obvious failures. They're the candidates who look right on paper, interview well, and then gradually reveal that the job they were hired for isn't the job that actually needed doing.
The person who gets you through one stage may not be the person who gets you through the next. This isn't a reflection of their capability. It's a reflection of the fact that the job changed.
| Stage | Timeframe | Profile required | Common brief error |
|---|---|---|---|
| Pre-clearance | 12–18 months before | Medical Affairs, Clinical Sales, Market Access (not VP Sales) | Waiting until clearance to begin commercial work |
| Post-clearance, early | Months 1–18 | Builder: ambiguity-tolerant, creates process from nothing | Hiring a scaled-company VP Sales to build from scratch |
| Early scale | Months 18–36 | Structured executor: systematic hiring, territory discipline, training | Carrying the early-stage builder into a structured execution role |
| Scale and optimise | Year 3+ | P&L-accountable commercial leader with team development depth | Promoting the early-stage hire rather than making a planned transition |
Pre-clearance: shaping the market before it exists
The commercial work that happens before regulatory clearance is consistently underestimated. In the twelve to eighteen months before a clearance is anticipated, the commercially intelligent device company isn't waiting. It's mapping the clinical landscape, identifying key opinion leaders, generating early evidence that will support both clinical adoption and payer engagement, and beginning the market access strategy that will determine whether the device has a reimbursement pathway on the day clearance lands.
The right commercial hire at this stage is rarely a VP Sales. It's more often a Medical Affairs lead, a Clinical Sales specialist with strong KOL relationships, or a VP Market Access who can begin the reimbursement strategy before clearance makes it urgent. Companies that wait until clearance to start building the commercial function typically find their commercial window is already narrowing by the time the first senior hire is in post.
Post-clearance, early stage: proving the model
The first twelve to eighteen months after clearance is the most demanding commercial environment a device company will face. The product is cleared but the market doesn't know it exists. No established territories, trained commercial team, or CRM infrastructure. No playbook. The question of who should be sold to, at what price, and through which channel had no precedent to draw from.
The commercial leader required here is what we'd call a builder: high tolerance for ambiguity, capable of creating process from nothing, comfortable operating without infrastructure, motivated by the challenge of establishing something that hasn't previously existed. They need to define the commercial model, make the first hires beneath them, engage directly with clinicians and procurement teams, and adapt rapidly when the initial assumptions prove wrong.
What this profile is not: a VP Sales who has spent a decade managing established territories in a large device company. That candidate has built deep expertise in a scaled commercial environment, optimising systems that others created rather than building new ones. They're excellent at running a machine that already exists. They haven't built one from scratch, and the skills don't transfer as cleanly as a strong CV suggests.
Early scale: building what the model proved
Somewhere between eighteen months and three years post-clearance, the commercial model shifts. Lighthouse accounts are established. The basic territory structure is defined. Early revenue is coming in and the pattern of where it comes from is becoming clear. The organisation now knows which buyer engages, which clinical champion converts, what the sales cycle looks like in practice.
A builder who thrived in the ambiguity of the early stage may struggle with the transition to structured execution. Systematic hiring, consistent training, territory discipline, converting early learning into a repeatable process: these become the primary demands, where previously problem-solving and resilience were.
Companies that don't recognise this transition tend to carry their early-stage commercial leader into a job that has fundamentally changed around them. Their leader continues doing what made them successful in stage two, which is less and less of what stage three requires. The performance gap is real but difficult to diagnose: the individual hasn't changed, but the role has.
Scale and optimisation: managing what the team built
By year three and beyond, the commercial function requires a different kind of leadership again. Forecasting accuracy, P&L accountability, territory management at scale, commercial team development: these become the dominant demands. The leader who gets a device company through its first eighteen months of commercial life is almost never the right leader for this stage.
The companies that manage this transition deliberately, rather than waiting for the performance gap to become a crisis, are the ones that scale without losing a year.
The conversation nobody wants to have
The most uncomfortable implication of this framework is that the person who got you here may not be the person who gets you there. Device company leaders frequently know this and avoid acting on it, because replacing a commercial leader who has worked hard and contributed genuinely feels like a betrayal.
The result is that the transition happens twelve months late, at higher cost to the organisation, and under circumstances that are harder for everyone involved. Leaders who handle this well treat stage transition as a predictable challenge and plan for it in advance, rather than responding to it as a crisis when the performance gap is already visible on the board deck.
The brief error this produces
The most common brief error in medical device commercial hiring is writing the brief for the stage the company is imagining rather than the stage it's actually in. A CEO opening a search at post-clearance, early stage, who writes a brief for a scaled commercial leader, is searching the wrong talent pool and assessing candidates against the wrong criteria. The hire is set up to fail before the search has begun.
One question tends to cut through this faster than anything else: which stage are you actually hiring for?
Not the stage you hope to be at in two years, and not the one your investors want to see in the board deck. The stage the business is at today, and the stage it will be at for the first twelve months of this person's tenure.
That answer determines the profile. The profile determines which talent pool you search, and how you run the search. Getting that sequence right is the difference between a commercial hire that accelerates the company and one that delays it by a year while it finds the right person the second time.