Julie Howard interviews Josh Rancourt on the differences between US and European field medical roles, the value of cultural fluency, and where AI fits in.
Is It the Same Role?
Julie: We kicked things off with a bit of transatlantic fun (a “Europe versus the US” theme, complete with props), but the real question underneath it is one we keep coming back to: is field medical, is the MSL role, actually the same job in Europe as it is in the US?
Josh: It’s a great question, because companies heavily based in the US often just “lift and shift” a US job posting into Europe, copying across requirements as if the role is identical everywhere. I’d ask: what actually makes hiring an MSL in Boston different from hiring one in the UK?
Julie: The similarities are the easy part: scientific credibility and communication skills are universal; the ability to hold a genuine peer-to-peer conversation with a physician, not just chat over a beer, is what makes a good MSL everywhere. Where it differs is understanding the local environment. The US is essentially one healthcare system; across Europe, every country has its own regulations, setup and standard of care. A study designed in the US and rolled out to Europe often misses that the standard of care, recruitment pathways, or even patient referral geography, simply aren’t the same.
Josh: If I were parachuted into London as an MSL, geography itself wouldn’t be my biggest issue. The US is huge too, and medicine is practised fairly consistently across it. My real challenge would be the treatment pathway: in the US I might go straight to a top KOL or their advanced practice provider, but there are no advanced practice providers in the UK, just physicians, and in fields like rheumatology, specialist nurses are far more central to patient care than I’d assume. On top of that, most MSL resources are built for the US market and only partially translate. How does your team manage that, covering multiple countries with different regulatory environments and products?
Julie: Experience is the biggest factor: most of our team has twenty-plus years in field medical and medical affairs, with strong clinical or scientific backgrounds. They are MDs, PhDs, pharmacists and MBAs who know their therapy areas and local subtleties well. Local language matters hugely too. KOL conversations happen comfortably in English, since it’s the language of science, but the finer details that matter with clinical trial and site teams (protocol nuances, hospital politics) can get lost unless you’re speaking the local language, which is a real advantage for our Polish, German and other local colleagues working directly with site coordinators. And structurally, US-built reporting frameworks often don’t have a “box” for the kind of insight European teams bring back, which means having the confidence to push back and explain what’s actually relevant in-market.
Josh: We’ve both seen resources built and rolled out from the US that just don’t land the same way elsewhere. It’s not just translation, it’s cultural nuance too.
Julie: Exactly. And ideally, bringing the European team in earlier means we can flag “this won’t land in the UK, Polish or German market” before it’s built, rather than after.
Bringing Field Medical In Early
Josh: That’s a strong case for bringing field medical in early: not just at the end of Phase 3, but early enough to shape recruitment itself, since US-centric approaches to reaching patient organisations and physicians don’t always translate.
Julie: There’s a perception that field medical is expensive to bring in early, but weigh that against the cost of delay at Phase 3. On projects we’ve worked on together, we were brought in at Phase 2B for site selection and feasibility, drawing on our own networks and understanding of the local environment to suggest sites, and that study recruited really well. Compare that to the old rescue-squad model, where MSLs only get called in once a trial is already in trouble. Those of us of a certain age would call it the A-Team approach. Very experienced MSLs can rescue a struggling trial well, but if you’d brought them in earlier, there’d be nothing to rescue: you’d already have the right standard of care, measures and endpoints built into the Phase 3 design, and no lag at the start of enrolment.
Josh: There’s real value even beyond avoiding those missteps: recruiting on time in a competitive environment is a significant saving over waiting until later and course-correcting. It also raises the question of who actually counts as a KOL for that kind of early engagement. In the US we look at top prescribers by claims data or publication volume, but the people who present at US congresses aren’t necessarily the right people to get a European study off the ground, and it’s often systems, not just individuals, that drive enrolment outside the US.
Who Is a KOL?
Julie: That’s one of the biggest questions in my career: what a KOL actually is varies a lot. In the US, relationships tend to be built with individuals; in Europe, we often have to build them with institutions first, then the individuals within them. The mapping exercise looks quite different as a result.
Josh: In the US it’s fairly standardised (claims data, publications, trial recruitment history) and you rank your top KOLs from there. Outside the US, that data often isn’t available at an individual level, and running the same methodology can leave you with only two or three genuine KOLs in a country. How does an experienced team identify the right people without that data?
Julie: It comes down to understanding local drivers. In the UK, for instance, the old financial incentives for investigators to join trials (where trial income funded more nursing staff or capacity for their unit) have largely changed, so you’re looking for people genuinely motivated by research and patient outcomes, not funding. Geography matters too, in non-obvious ways: the UK is a genuinely disparate country, and two study centres ten miles apart might draw from completely different referral populations, or two centres that look independent on paper might actually compete for the same patients. You need people with a genuinely holistic, on-the-ground view: the kind of “who’s really the right person” nuance that desktop research alone won’t surface, particularly in sub-specialties like rheumatology where your obvious top five names, found by a quick search, might not even cover the area you’re actually studying.
Josh: It reinforces that this isn’t just local knowledge, it’s knowledge of the healthcare system itself. And because there’s so little public data to draw on in a lot of these countries, it really comes down to having an experienced team already on the ground, with established relationships, who can speak intelligently enough to actually shape how a trial is designed or who gets selected.
Can AI Replace an MSL?
Julie: That local-insight theme leads naturally into AI. Can it replace an MSL, or specifically, an experienced one?
Josh: I don’t think it’s that simple. AI is good at surfacing scientific information if you know what to ask, but it doesn’t bring personal knowledge or contact. The real MSL value increasingly isn’t just delivering information: it’s identifying the question behind the question a clinician is really asking, and knowing what to do with the answer.
Julie: Patients are increasingly using AI themselves to research trials, so the volume of information everyone’s dealing with is exploding. But some of the most valuable insight I’ve gathered has come from unplanned moments in conversation: something a clinician raises that doesn’t fit a CRM’s existing categories, but which then reshapes what you track going forward. Asking good questions of AI is something both junior and senior MSLs can do; what separates experience is knowing what to do with what comes back. That said, AI is brilliant for the “donkey work” (background research, drafting a conference report), saving days of legwork.
Josh: It still misses on tone, though: technically correct wording that doesn’t sound like how clinicians actually talk to each other, the same way ill-judged US marketing phrasing sometimes hasn’t translated. And when AI doesn’t know something, unlike an MSL, it doesn’t say so. It hallucinates rather than admitting the gap.
Julie: Which is really the whole case against AI replacing us: it can’t build a relationship the way a person can. We’ve talked before about “canned empathy” (AI attempting warmth that reads as scripted rather than genuine), a bit like a friend who’s just been on a communication-skills course and now talks entirely in workshop phrases. People still want to pick up the phone and speak to someone who understands them.
Josh: Technically, it’s frustrating. As much as we lean on new tools, when it comes down to it, people want to talk to people they like and trust, who have the information they need. That personal touch hasn’t been replaced yet.
Julie: And I think COVID genuinely changed what’s possible here: it normalised virtual contact and made conversations like this one, me in the UK, you in the States, completely unremarkable, in a way they wouldn’t have been a few years ago. But there’s still a balance to strike between virtual efficiency and the value of real time in the field, building the kind of rapport that lets you later just pick up the phone for a quick, informal chat.
Depth vs. Breadth, and Cultural Fluency
Julie: There’s a phrase I like: a US MSL can go deep, but a European MSL has to go wide and deep. In the US, roles can be hyper-specialised (solid tumours, or haematology, as separate lanes). In Europe, leaner teams mean covering multiple therapies or products at once, while still needing that same depth of local, cultural knowledge, which is something we’re keen to make a real differentiator at Phoenix. Cultural fluency isn’t just about language either: it’s understanding that Europe isn’t one regulatory environment the way the US, under a single FDA, essentially is. We’re operating across more than two dozen individual countries, each with its own standards, on top of those of us who sit outside the EU altogether. Understanding how those layers interact, and how a product might launch faster in Spain than the UK on the same overall timeline, is close to a specialism in its own right.
Josh: That’s a genuinely different challenge. How much can that cultural fluency actually be trained, versus simply needing time and experience?
Julie: Both, probably, but time is exactly what many biotechs don’t have. Building a permanent, full-time headcount team across Europe can take six to twelve months to hire, and another six to twelve to become fully operational. A cohesive team that’s already worked together, with local relationships and KOLs already in place, doesn’t need to be trained into the culture or the market. That’s what we’re proud of at Phoenix: a boutique, pan-European team that already knows how to lean on and support each other, rather than a group of individually-recruited strangers assembled country by country.
Josh: I’ve built medical affairs teams from scratch at several start-ups, and training someone properly into the MSL role typically takes twelve to eighteen months. When speed matters, you don’t have that luxury: you need a team that can be effective within four to eight weeks, which is exactly the gap a ready-formed, experienced team fills. And having watched your team work, that camaraderie isn’t artificial. It clearly comes from having worked together before, which lets people work efficiently and cross-functionally from day one.
Julie: Exactly. The value isn’t just the individuals, it’s a team that already gets each other and thinks the same way about problems. That’s difficult, and expensive, to build from scratch.
Josh: To put it in context for sponsors newer to Europe: even within the US, cultural fluency matters more than people expect. Early in my career, after a site visit in South Carolina, I was told, “you’ve been amazing down here, bless your heart”, not realising that wasn’t quite the compliment it sounded like. If that nuance exists within one country, the risk of unintentionally causing offence multiplies enormously across European markets. Cultural fluency isn’t a nice-to-have, it’s what stops you tripping over relationships you don’t even know you’re damaging.
Julie: Almost certainly true of a fair few people I’ve met too. Josh, it’s been an absolute pleasure. Thank you so much for your time, and for a really great discussion.