One of the most common questions I get from founders: "Should I hire a full-time CTO or work with someone fractional?"
The honest answer is that it depends. But I can give you a framework for thinking through it.
What a CTO Actually Does
Before we compare models, let's be clear about the CTO role. At early-stage health tech companies, the CTO typically owns:
- Technical architecture: system design, technology choices, scalability decisions
- Engineering team: hiring, management, performance, culture
- Technical roadmap: what gets built, in what order, why
- Compliance architecture: HIPAA, SOC 2, FDA if applicable
- Technical due diligence: investor conversations, partnership evaluations
- Vendor relationships: cloud providers, third-party services, contractors
That's a lot. The question is: how much of this do you need right now?
When Fractional Makes Sense
Stage: Pre-Product or Early Product
If you don't have a product in production yet, or you're early post-launch, you probably don't need 40+ hours/week of CTO time. You need:
- Architecture decisions made right
- A technical roadmap that makes sense
- Compliance foundations laid properly
- Occasional investor prep
A fractional CTO can do all of this in 20-30 hours/month.
Team Size: Under 10 Engineers
Managing a team of 3-8 engineers doesn't require a full-time executive. It requires someone who can set direction, establish processes, and unblock people. That's fractional work.
Budget: Under $250K/year for Technical Leadership
A strong full-time CTO in health tech costs $250K-$400K+ (salary + equity + benefits). If that's not in your budget, fractional gives you access to the same caliber of leadership at a fraction of the cost.
Runway: Less Than 18 Months
If you're watching runway, fractional lets you get CTO-level guidance without the fixed cost. You can scale the engagement up or down as needed.
Situation: You Need Specific Expertise
Maybe you have strong engineers but no one with HIPAA experience. Or you're preparing for FDA and need someone who's been through it. Fractional works well when you need specific expertise rather than general leadership.
When Full-Time Makes Sense
Stage: Scaling Post-Product-Market-Fit
Once you have product-market fit and you're scaling, the CTO role shifts. You need someone embedded in the organization driving execution, not someone who shows up for 20 hours/month.
Team Size: 10+ Engineers
At this scale, the CTO role is more about people management, process design, and organizational structure. That's a full-time job.
Decision Velocity: High
If you're making architecture decisions daily, negotiating with vendors weekly, and hiring constantly, you need someone full-time.
Board Seat: Expected
If your investors want a CTO on the cap table as part of the founding team, that's a full-time role with equity compensation.
The Hybrid Model
Many of my clients use a hybrid approach:
Phase 1: Fractional CTO to establish foundations (3-6 months)
- Architecture decisions
- Compliance frameworks
- Hiring first engineers
- Technical due diligence for raise
Phase 2: Hire a strong VP of Engineering or Technical Lead
- Day-to-day execution
- Team management
- Product delivery
Phase 3: Either promote the VP to CTO or hire a full-time CTO
- Once the company has product-market fit
- When the role is truly a full-time job
The fractional CTO during Phase 1 often helps hire and onboard the VP in Phase 2. This gives you continuity without the cost of a full-time executive before you need one.
What Fractional Can't Do
Let me be honest about the limitations:
Deep People Management
If your engineers need daily 1:1s, career development conversations, and hands-on mentorship, that's a full-time job. Fractional can set the framework, but can't be there every day.
War Room Mode
If you're in crisis (production is down, a major deadline is looming, or you're pivoting rapidly), you need someone full-time in the room.
Organizational Politics
In larger organizations, being part of the executive team means navigating internal dynamics, building relationships, and influencing without authority. That's hard to do part-time.
Questions to Ask Yourself
How many hours/week of CTO work do I actually need right now?
- If it's less than 40, consider fractional
What specific outcomes do I need from technical leadership in the next 6 months?
- If it's a defined set of deliverables, fractional works well
Do I have someone who can handle day-to-day execution?
- If yes, fractional for strategy + execution support works
- If no, you may need full-time or a VP hire first
What's my budget for technical leadership?
- Full-time CTO: $250K-$400K/year (total comp)
- Fractional CTO: $10K-$25K/month depending on hours
Am I raising soon?
- Investors sometimes prefer full-time, but many understand fractional at early stages
- What matters is whether you can articulate your technical strategy and have credible leadership
Red Flags to Watch
With Fractional:
- The fractional CTO isn't available when you need them
- They're spreading too thin across too many clients
- You're not getting enough hours to make progress
- Architecture decisions are taking too long
With Full-Time:
- You can't afford the caliber of CTO you actually need
- The CTO is underutilized and creating work to justify their role
- The role doesn't have enough scope for a senior executive
- You hired for prestige instead of fit
My Recommendation
For most health tech startups from pre-seed through Series A, I recommend:
- Start fractional. Get the foundations right with experienced guidance.
- Hire execution-level. Bring on a strong VP or senior engineers.
- Evaluate at Series A. Decide if the role is now full-time.
This approach gives you:
- Senior expertise when you need it
- Lower burn during cash-constrained phases
- Flexibility to scale up or change direction
- Time to understand what you actually need from the role
If you're trying to figure out what makes sense for your company, book a call. I'm happy to talk through your situation, even if the answer is that you should hire someone full-time instead of working with me.
