Medical Affairs in Small Biotech: Lessons from Rachel Couchenour of Travere Therapeutics

At the Medical Affairs Professional Society (MAPS) 2025 Americas meeting, a session on building and leading Medical Affairs in a resource-constrained environment drew a packed room both times it ran. Many attendees were running Medical Affairs organizations of one to five people, with the same expectations as large pharma and far fewer hands.

In Episode 14 of OnPoint: The Medical Excellence Podcast, Scott Thompson talks with session co-presenter Rachel Couchenour (Travere Therapeutics), Vice President of Global Medical Affairs, about the thinking behind that talk. Rachel walks through the four pillars Medical Affairs owns at any company size (evidence generation, stakeholder engagement, scientific communications, and medical education) and how to sequence them when the team is small. She explains why the scientific communications platform has to come first. A scientific communications platform is the agreed set of core scientific statements and terminology that every function uses to describe a disease state and product consistently. The conversation also covers internal stakeholder mapping, getting more from agency partners, hiring for less structured environments, what to ask before joining a small company, and the story behind Flossy the Focused Flamingo. If you're moving from large pharma to a lean team, start here.

Key Takeaways

• Build the scientific communications platform before you deploy the field. Under pressure from her executive team at her first startup, Rachel hired a contract MSL team before a scientific communications platform or lexicon existed, and found that "no one was talking consistently about our disease state." Looking back, she calls it her biggest mistake: "They hired me, they hire us to think, and I just went and executed without thinking." Her lesson: "one of the places you have to start is in your scientific communications, building those foundations through your scientific communications platform and agreeing on that across the organization."
• Sequence the work instead of doing it all at once. Small and emerging biotechs are often single-asset companies, so Rachel focuses on what will make the biggest impact now. "Sometimes you have to sequence it," she says, and "We can't boil the ocean." The tradeoffs are real: her team gave up a headcount that led operational excellence to fund a digital innovation function after learning that nephrologists engage and hold journal clubs on X.
• Bring internal stakeholders along. "You have to bring them along," Rachel says. She maps her internal stakeholders, sets up regular one-on-ones, and opens each by asking what they need and expect from Medical Affairs. Her reasoning: "No one likes to be surprised, everyone wants to feel like they have a say."
• Design content and partnerships for reuse. Rachel's team avoids recreating website or digital content that MSLs or the scientific communications team have already developed. She is also launching what her team calls an "agency ecosystem," bringing agency partners together to review top initiatives. "We're gonna require our agencies to talk to each other," she says. "Our budget is our budget. But we want the people that can help us do it most efficiently."
• Hire for attitude, then teach. For less structured environments, Rachel weighs "their knowledge, their skills, and their attitude. We can't teach an attitude or a behavior." She frames growth the same way: "I like to think of career development not as a ladder," but as a dome-shaped jungle gym where moving sideways builds experience and exposure.
• Move from activity counts to outcomes. Rachel's focus for the years ahead is showing the impact of Medical Affairs, which she says has been "stuck in capturing activity" because its work takes longer to show results. She wants to "find some surrogate outcome measures." The gap shows up in industry data: in a 2025 global survey of 1,023 Medical Affairs professionals published in Pharmacy, 92% of respondents said their organizations measure MSL performance by number of KOL engagements, while only 3% rated current KPIs as very effective.

About Our Guest

Rachel Couchenour, PharmD, MBA, is Vice President of Global Medical Affairs at Travere Therapeutics, where she has helped grow the company's global Medical Affairs organization and led Medical Affairs for its first launch in rare kidney disease. She previously served as head of US Medical Affairs at Novartis Gene Therapies, where she was involved in launch strategy for a systemic gene therapy, and held earlier roles at companies including Sanofi and Lundbeck. Rachel has worked in rare disease for the last 15 years, with experience spanning early-stage development through post-launch strategy, KOL engagement, and scientific communications.

Connect with Rachel on LinkedIn: https://www.linkedin.com/in/rachelcouchenour/

FAQ

What should a new Medical Affairs leader in a small biotech prioritize first?

Rachel Couchenour of Travere Therapeutics recommends starting with scientific communications. Early in her career, she hired a contract MSL team under pressure from her executive team before a scientific communications platform or lexicon existed, and found that "no one was talking consistently about our disease state." Her advice: "one of the places you have to start is in your scientific communications, building those foundations through your scientific communications platform and agreeing on that across the organization."

How can a small Medical Affairs team cover evidence generation, stakeholder engagement, scientific communications, and medical education with limited resources?

Rachel Couchenour recommends sequencing the work rather than doing it all at once, focusing on what will make the biggest impact now, especially in single-asset companies. "We can't boil the ocean," she says. Her team also stretches resources by reusing content across MSLs, the website, and digital channels, and by asking agency partners to coordinate through what her team calls an "agency ecosystem."

How does Rachel Couchenour build internal support for Medical Affairs?

Rachel Couchenour maps her internal stakeholders and sets up regular one-on-ones, opening each by asking what they need and expect from Medical Affairs before describing what her team can offer. "You have to bring them along," she says. She also shares plans before they are fully finalized so colleagues have room to give input.

What should a Medical Affairs leader ask before joining a small biotech?

Rachel Couchenour looks at the company's funding trajectory, including whether it has enough money to get through its pivotal trials, and at the reputation of the CEO. She reads quarterly earnings and analyst commentary, and during interviews she asks about plans and resourcing for Medical Affairs. In her first small biotech, she did not ask those questions and later realized she was "never gonna get any headcount."

How should Medical Affairs measure its impact?

Rachel Couchenour notes that Medical Affairs work takes time to show results, which is why the function has been "stuck in capturing activity." She wants to "find some surrogate outcome measures" that connect activity to what the function is trying to achieve. A 2025 global survey of 1,023 Medical Affairs professionals published in Pharmacy found that 92% of respondents said their organizations measure MSL performance by number of KOL engagements, while only 3% rated current KPIs as very effective.

Curious how this applies to your organization? Let's talk.

About OnPoint: The Medical Excellence Podcast

OnPoint: The Medical Excellence Podcast delivers insightful conversations on the most pressing issues facing top Medical Affairs professionals. Listen to stay ahead of industry trends and be inspired by leaders shaping the future of Medical Affairs.

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