In an hour-long meeting at Eli Lilly and Company’s headquarters in Indianapolis on April 15, the pharmaceutical company’s top executives met, like they had dozens of times before, to hear the long-awaited results of a study involving a new drug.

There’s always a lot riding on these presentations, called readouts. But this one, for Lilly’s first diabetes and weight-loss pill based on the GLP-1 hormone, was particularly fraught. Days before, rival pharma giant Pfizer had announced it was abandoning its oral weight-loss drug after worrying side effects involving liver problems were reported in one participant in the trial. It was the second drug in its class that had failed for Pfizer.

So, David Ricks, Lilly’s CEO, was understandably cautious. It was the latest in a string of milestone moments for the understated leader of the country’s most dynamic pharmaceutical company. Lilly executives took TIME inside the complex process of developing the new pill that unfolded over a series of conversations and a visit to the company’s headquarters and labs in Indianapolis to detail both the scientific advancements as well as the unique culture at the pharma giant that made the drug possible. And now it all came down to this meeting. Early phase studies had been promising, but anything can happen when a new drug is tested on thousands more people.

“In my job as CEO, I’ve walked into a room like that about 30 times, and most of them have been for successful drugs—but there have been failures,” he says. “You can kind of tell by the way people are sitting what the outcome is going to be. But what you don’t know is the degree