An interview with John Viel, Ph.D., a field medical affairs leader with 25 years of industry experience, hosted by Julie Howard, Ph.D.
Julie: John, thank you for joining us. You’ve spent 25 years in medical affairs, starting as a field-based MSL and rising through management to your current role leading a medical affairs team. We’d love your perspective on how the field is evolving — particularly the decision biotechs face between building a permanent headcount team and borrowing capability through a contract or consultancy model.
John: Thanks for having me. I’ve had the chance to build not just field medical teams but entire medical affairs departments from the ground up, so I’m glad to share what I’ve learned.
Why Europe Gets Left Behind
Julie: Let’s start with that build-versus-borrow question. Many biotechs are US-based with no established European presence. When they’re deciding whether to build their own team or borrow one, what’s the first thing they should consider?
John: It comes down to the fundamentals of what you actually want your field team to do. The industry is moving on from an old, all-or-nothing playbook that was heavily US-focused and neglected Europe. That’s hurt smaller companies especially — they miss European conferences, global expert relationships, good science, and clinical insight, along with genuinely different approaches to therapy that exist across the Atlantic. Bringing more flexible, fractional models into the mix is an overdue evolution — honestly, it should have happened 20 years ago.
Why Wait for Phase 3?
Julie: Field medical teams are typically brought in around phase 3, often once studies are wrapping up or running into challenges. What’s the case for bringing them in earlier?
John: It makes far more sense to have that European perspective from early on. Standard of care — when treatment starts, when it’s discontinued, when clinicians escalate to the next therapeutic option — can vary meaningfully between the US and Europe. You need that full picture to properly plan things like responder analyses or to understand differences between patient populations. Without the most inclusive approach, you’re missing information that could determine your program’s success or failure.
The Risk of Building Too Early
Julie: The flip side — what’s the cost of building too early, or too big?
John: The more common problem, honestly, is teams being overbuilt right before launch — a large team assembled in a rush for a disease area that may not need it. That’s usually driven by necessity: companies scrambling to identify true community experts, as opposed to the investigators who happened to run their phase 3 trial, in time for launch. It doesn’t have to be this way — this “build big right before launch” pattern has just become the accepted norm over the last decade or so, more out of habit than strategy.
Julie: To be clear — “build” here means permanent headcount. Bringing a team in earlier doesn’t necessarily mean building permanent staff early; it could mean borrowing or outsourcing a team, just deployed at the right time.
Two Ways to “Build”
John: There are really two versions of a build model. The traditional approach is a large contract team that substitutes for a full internal team — common in the US, with real trade-offs. The stronger alternative is a fractional model built around a smaller group of genuine experts. It creates the opportunity to build high-quality relationships with people who bring both industry and therapeutic expertise. There’s no substitute for that kind of relationship and scientific credibility, and from a cost-versus-results standpoint, it’s the model that makes the most sense.
Local, Fractional Teams vs. Full-Time Travelers
Julie: The traditional model assumes full-time, 40-hours-a-week dedicated staff. But with rare diseases, limited sites and limited patients, is there a case for more fractional, locally-based team members — say, two to three days a week each — rather than a small team of full-timers criss-crossing Europe, sometimes missing protocol nuances that only come up in the local language?
John: If I’m building a team, someone having multiple projects wouldn’t put me off, provided they have the expertise, judgment and local insight I need. It comes down to how well you can build relationships early. People who are local-language fluent, who know the geography and the nuances of the patient population, bring something a bigger team of relative newcomers simply can’t — those newcomers often need months just to get up to speed on the disease state, and tend to be more junior. I’m genuinely open to rethinking how we approach early-stage development programs along these lines.
Timelines: Months vs. Weeks
Julie: Timeframes matter a lot here too. A full-time, permanent European team can take six to eighteen months to onboard and become fully operational in the field. With an experienced consultancy team, we think that can shrink to a matter of weeks, largely because of the relationships and experience they already bring. If you had one piece of advice for a CMO or medical affairs lead building a team for a phase 2b or phase 3 study — headcount versus fractional — what would it be?
John: Strongly consider bringing medical affairs in at the start of phase 2, and don’t feel bound by what the traditional model says you should do. In an early-stage company developing its first compound, budget drives everything — your executive team is watching spend on team-building closely, especially with fundraising pressures. Building a big team from scratch isn’t necessary that early. Getting experienced, well-qualified people on a fractional basis makes a lot more sense.
Not Either/Or
Julie: It doesn’t have to be a choice between speed and quality. In an ideal scenario, you borrow your team early via a consultancy, and that same team can later help train up a permanent team once the product nears launch — the right approach really depends on the company and where the product is headed. It also gives experienced and less-experienced consultants a chance to work together, which addresses something field medical has long struggled with: a clear career path.
John: Exactly — the two paths aren’t mutually exclusive. The fractional approach gets you moving fast, and those same experienced people can season and train your full-time team as you scale up hiring. We need to rethink what “efficient” looks like in medical affairs — it’s not just tiny teams working to the bone or huge teams that take forever to reach full speed. There’s a sweet spot in the middle that’s both more effective and more cost-efficient.
Rethinking “Pre-Launch Only”
Julie: Shifting topics slightly — field medical is often treated as a pre-launch activity by default. Do you agree with that assumption?
John: No. That’s become embedded in planning, tied to when commercial teams get built out, but there’s a strong case for bringing medical affairs in much earlier. Done right, it’s not just a relationship-builder — it makes the clinical team itself more effective, because they’re working hand in hand. The rationale really needs a 180-degree turn: instead of an afterthought before launch, it should be one of the earliest pieces helping to build the clinical program itself.
Justifying Earlier Investment to the Budget Holders
Julie: What’s the risk of deploying too early, and if you go with a consultancy model, how do you avoid paying for capacity you don’t use? How would you justify bringing a team in earlier to budget holders?
John: A fractional approach gives you a lot of flexibility — it’s the same logic behind the “fractional CMO” or “fractional CFO” trend, and it applies just as well to medical affairs. Every CEO you’re trying to convince will want the budgetary case: that this makes the company more cost-effective, not less — a development activity, not just a cost center. A lot of that early relationship-building work — vetting the KOLs who are genuinely passionate about your program, not just the sites on a list — often gets left to the CRO by default. Having an experienced medical affairs team build those relationships and identify real clinical and scientific champions in phase 2, rather than waiting for phase 3 data, is an invaluable asset.
Field Medical and CROs: Partners, Not Substitutes
Julie: That raises a common objection we hear: “we don’t need field medical yet, the CRO knows the sites.” How do you frame the relationship between a CRO and a field medical team, and why you need both?
John: CROs are equally stretched — they’re juggling multiple clients and working from site lists that, in some cases, a good medical affairs team can help refine for more efficient targeting. I’ve seen that collaboration work well firsthand. It should be approached the same way you’d collaborate with internal clinical development — everyone rolling in the same direction. The more you can support the CRO and make them more efficient, the more you boost your company’s development timeline: best case, you accelerate it; worst case, you maintain it. That’s the strongest pitch to a C-level audience focused on clinical development efficiency. People who understand the science, the drug, and who the CRO contacts are bring real value to sites — and the sites are really your customer. You want to help them get up to speed quickly, including all the IRB and internal documentation.
The Hidden Costs of US-Run European Studies
Julie: Programs often launch in the US and expand into Europe while still being managed by US-based, full-time headcount teams overseeing European sites — often ones recommended by CROs. What are the challenges with that model compared with using locally distributed teams?
John: A few things could be made more efficient. First is budget fidelity — you’re not paying US staff to fly to Europe to build relationships; local people keep travel costs minimal with little impact on the overall development budget, while still maintaining or accelerating your timeline. Second is local nuance — no matter where you’re from, if you’re not from that site’s country and city, you lose something. Third is work-life balance. Middle-to-late-stage development is one of the most stressful, highest-visibility periods for a company, with investors and analysts watching public timelines closely. Working people to death and losing them to turnover isn’t the way through that — a locally distributed model helps with both retention and timeline delivery.
Burnout and Retention
Julie: That burnout piece resonates — we’ve all lived through running multiple countries, conference to conference, site to site, and it’s a topic coming up a lot on LinkedIn and elsewhere. Someone working two or three days a week, locally, can bring that burnout down significantly, especially once you factor in transatlantic travel and time-zone differences.
John: So many people I’ve worked with over the years have left roles because of exactly this — missing time with family, with kids. I’ve been guilty of it myself earlier in my career. Saying no is genuinely hard for driven, motivated professionals, and that’s often what gets people into trouble. Burnout frequently comes without warning — someone gets home from a trip and hands in their two weeks’ notice because they’ve hit their limit. Turnover during a phase 2 or 3 program is enormously costly, and it costs relationships too — the ones you’ve built with colleagues over time. Helping retain good people is one of the strongest pitches you can make to an executive team, because they will recognize the risk. The same pattern shows up at sites too, with clinical trial managers and study nurses — high turnover there slows everything down and effectively resets a program back to zero.
Balancing Experience and Enthusiasm
Julie: There’s a paradox here — more experienced people learn when to say no, but younger, less experienced staff are often more willing to say yes to everything. How do you strike that balance?
John: Ironically, younger, less experienced people are often more prone to early burnout, precisely because they haven’t learned to set boundaries yet. As I’ve gone deeper into my career, my coaching to younger colleagues is: take your time — the company will still be there when you’re back. A vacation just postpones the work either way, but it matters for mental health. Some of the best young MSLs I’ve seen — the most passionate, the ones who want to go to every meeting and every site — are exactly the ones who flame out fastest. It’s rarely a slow burn; it’s a sudden message after a trip saying they’re done. You have to manage that early, and manage each person differently, because everyone’s different. If you don’t help people see when to take downtime, you’re at real risk of losing them — and on a small team driving a development program, losing one person isn’t a minor setback, it’s a major crisis.
The Value of a Pre-Formed, Cohesive Team
Julie: That connects to something else — replacing a team member mid-project is slow, whether it’s a full-time hire or even a consultant. One thing we believe Phoenix brings to the table is a fully-formed, cohesive team rather than a set of individuals: people who’ve already worked together, know how each other communicates, and can step in for one another when needed. If you had the choice between twenty individuals with great CVs versus a team that’s already proven it works well together, what would weigh most heavily in that decision?
John: Two things you mentioned would be strong motivators for me. First, bringing in a team that’s already functional, rather than a group that has to build trust and working rhythm from scratch — that process typically takes a year to a year and a half, so avoiding it is a real advantage. Second is local knowledge and seasoned experience — Seattle and Miami are different worlds within the US, and the same is true comparing the EU and the UK. For real efficiency, you need people who understand that local nuance. Combine that with the cost-effectiveness of a fractional model — which minimizes risk while maximizing potential — and those factors would weigh heavily for me.
Final Advice
Julie: Last question — if you could give one piece of advice to an emerging biotech building a team across Europe to support their clinical trials, what would it be?
John: Think outside the box. Be willing to consider ideas that have already proven successful in other functions, and seriously consider a fractional model — it’s something that can genuinely help accelerate your timelines.
Julie: John, thank you so much — it’s been a real pleasure.
John: Of course.