Understanding the past can often help create clarity for the future. Many industries are changing rapidly these days and Fertility practices are not immune. Changes from scientific advancements, culture, and consumers all play a role in the landscape shift of the industry. When you add technology to the mix, advancements start snowballing rapidly.
This week on Inside Reproductive Health I interviewed Dr. Robert Stillman, a Board Certified Reproductive Endocrinology and Fertility subspecialist with over 40 years of experience. We recount his experience from beginning to the present and what he deems will be important in the future. He has direct experience with the integration of private equity capital into fertility practice and has led trends in practice financing, technology (e.g. AI, genetic testing, egg freezing), physician and staff recruitment, retainment, compensation, partnership tract, and retirement paradigms.
In this episode, we talk about Dr. Stillman’s insight into the industry and big trends we are seeing including how Artificial Intelligence is and will continue to shift the industry. We also talk about:
How Private Equity effects Fertility Practice
What changes have happened in the Fertility field over the last 20 years
How has consolidation and expansion has affected the REI landscape
How Bob was able to successfully work with the academic centers
To learn more about our Goal and Competitive Diagnostic, visit us at FertilityBridge.com.
Transcript:
Dr. Robert Stillman: You have to forage where you, where you are, but also that you don't necessarily pillage. Every place you take over, you can synergize with the medical centers there, you can synergize with other groups you can consolidate for their benefit
[00:00:16] Narrator: Welcome to inside reproductive health. The shop talk of the fertility field here, you'll hear authentic and unscripted conversations about practice management, patient relations, and business development from the most forward-thinking experts in our field Wall Street, and Silicon Valley both want your patients, but there is a plan.
[00:00:35] If you're willing to take action, visit fertility bridge.com to learn about the first piece of building a fertility marketing system, the goal and competitive diagnostic. Now here's the founder of fertility bridge and the host of inside reproductive health Griffin Jones.
[00:00:53] Griffin Jones: Today on inside reproductive health.
[00:00:55] I talked to Dr. Robert Stillman. We talk about a rich history of the field, how it's gotten to, where it is now with supply versus demand in the fertility field and where it's going with things like artificial intelligence at home care alternatives. To how the fellowship programs are structured. Now, before I get into this interview with Dr.
[00:01:17] Stillman today's shout out, goes to Dr. Neil . So I want to start thinking of the shout outs that are of people that did nice things for me early on in the field and Dr. Mohit at the time he's in Montreal, he was the president of the Canadian fertility and andrology society. I had just moved back to the United States.
[00:01:35] I didn't have two nickels to rub together hardly. And I emailed him asking if I could just come for a day, if I could come on, like the graduate student discount or whatever it was. And he was happy enough to oblige me, you're kind enough to oblige me whether he was happy about it. I have no idea, but it was a kind thing at a time when I was just getting into the field.
[00:01:55] And so I want to give today's shout out to Dr. Moot because I haven't talked to him in a long time and maybe. Someone will pass this along to them and I'll get an email from him, which would be nice on today's show with Dr. Stillman. I know that I have someone else from shady Grove on the show. This may be my fifth guests, maybe fourth or sixth guests from shady Grove that we've had on in the a hundred.
[00:02:17] And so episodes, if you don't like it, you can come on the show. If you think that I'm favoring one group and you have a countering opinion, you are more than welcome to come on to the show. This is a massive group. They make a massive amount of my audience because they're the size of a small Eurasian country and they have 85 doctors or so.
[00:02:39] And so it does make sense for me to have many guests from them. But if you want to give the counter view to any of the views that have been presented on the show, just let me know. I'll have you on the show. As long as it's cogent. And w in Dr. Stillman's case, he was the medical director of shady Grove for 20 years.
[00:03:00] He's now retired. He was the medical director emeritus, I suppose, that he is now he owns a company called fertility space consultants. So in retirement, Dr. Stillman is consulting other fertility centers. And I just find his perspective on where the field has been and where it's going to be extremely valuable.
[00:03:20] So if you're interested in artificial intelligence and the case loads of is in the responsibilities of what the REI and the fertility practice is going to be in the next decade or so, please enjoy this interview with Dr. Robert Stillman. Dr. Stillman Bob, welcome to inside reproductive health. Thank
[00:03:39] Dr. Robert Stillman: you.
[00:03:39] Thank you for having me,
[00:03:40] Griffin Jones: You know, there's a handful of people in the field that I didn't know before, either before the podcast or before we met that had tried to reach out. And very often when people do try to reach out to me, they're trying to get me to sell something. So inevitably, when somebody reaches out to me, they're I have a reaction of, gosh, what does this person want me to sell?
[00:03:58] And there's a handful of people that, you know, it wasn't about selling anything. It was about building a relationship and, and. And being on the same wave length, and there's, there's probably two or four people that I can think of that it's like, man, I'm glad that I took that call. And you're one of those people because you have an impressive resume.
[00:04:18]You also have a pretty holistic view of what the field will be. I mostly want to talk about the future or at least I think what's most important is the future, the near future, because the far future you can't really predict. And the past is the past, but the past is really important for understanding pattern recognition.
[00:04:37] And the far future is important for how we rank priorities in the near future and not just looking at what's immediately in front of us. So I want to talk about that. And I will, I will have given some of your intro in some of your bio in the intro to the show, but just talk to us about how you became to be one of the earliest partners of shady Grove and how you helped to build that thing with your partners, to what it came
[00:05:04] Dr. Robert Stillman: to be, right?
[00:05:05] Yeah. Again, thanks for having me. I feel the same way about the synergy. That's really been one of the hallmarks of what I've tried to do before shady Grove and, and during shady Grove is bring disparate or seemingly disparate groups and people together, academics and private practice and a whole variety of things.
[00:05:24] So this fit right in with that without again, trying to sell anything. And I, my time with shady Grove was both participating, but also at the feet of the masters, you've had them on Mike Levy and Mark Segal. Tremendous assets to to the field, with who and arts at Gaskin. And I'll get into the three partners in a second.
[00:05:44]But all of those including your prior podcasts are are worthy of listening to, for for your audience. So my career being the old guy spans the arc of the fertility field in that I started prior to the time that there was any human IVF successful. Okay. So my fellowship span was 77 to 79.
[00:06:08] So after college I trained at Georgetown Duke and Harvard and IAH and microsurgical training with, to Robert Winston in Hammersmith hospital. And that's interesting because that's a nostalgic, almost a Relic now of, but that's what we used to do with the field. We had Clomid we had inseminations, we had donor sperm and we had microsurgery of one kind or another as a burgeoning field and survivor Robert Winston was knighted because he pivoted from microsurgery where he was world renown to becoming one of the foremost proponents of IVF.
[00:06:41] And so when I went into academics, As a career manifest destiny towards the chairmanships, which is where my training was all destined to be. I became a professor and director at GW and started the IVF program there. One of the first in the U S the first birth in Washington in 1983. And then train the series of fellows seven of the nine of whom were became members of shady Grove, which is an interesting way to recruit physicians, which we can get into and then saw the limitations of academic practice.
[00:07:12]It couldn't, wasn't entrepreneurial enough as we needed to grow and develop and put resources and so on. So I left and joined Mike Levy and artsy Gaskin as the third partner at shady Grove fertility with Mark Siegel as the CEO. And two weeks later, we signed with Integra med because we needed capital to grow.
[00:07:32] And I've seen that entire component of benefit. I've seen downsides too, but I've seen the entire benefit of capital private equity and other w with integrity, Metta was an MSO and the ability and the requirement to grow, we would not have grown the way we did without the support and capital of integrity.
[00:07:53] We outgrew them after a while, and that's an interesting part of the story, but we needed any EMR. We needed to have people sign our loans without it being personal loans for growth and development we needed. To start insurance issues with an Arctic assisted reproductive technology insurance captive in the Caymans.
[00:08:11]We needed, we wanted to have retirement benefits that were stronger than our employees. We had really good wins for the employees, but we want a different ones. And if and so all our employees went to integrity. That wasn't the only reason, but it was helpful. So we then saw shady Grove go from three physicians to now 85 or so 150 cycles.
[00:08:33] When I joined in 97 to over 10,000. 220 employees to now over a thousand and now us fertility with another private equity partner ambulant partners. So I saw the and I served there for 20 years as a medical director until becoming a Meritus a couple of years ago and now retiring as of December.
[00:08:58] So I've seen the arc of the fertility IVF field, and I have a vision and not a unique one, but I have a vision from that perspective of what the future near future anyway, may hold. So
[00:09:10] Griffin Jones: if you signed with Integra two weeks after you joined with the group, you must have known that you were going for the Gusto, that this was to be a high growth venture.
[00:09:23] Was that part of what you were looking for?
[00:09:28] Dr. Robert Stillman: Yes, but I wouldn't say a high growth venture. We were looking for an organic growth without as much risk. So we got, yes, we got a really nice, we called it right to manage fee because they didn't, they didn't take any equity. And there's all sorts of obviously private equity capabilities of equity, ownership, equity, and non-equity.
[00:09:48] But this was a non-equity one, which is really one of the reasons we went with them.
[00:09:52] Griffin Jones: I don't really think of Integra med and organic in the same sentence, Bob.
[00:09:56] Dr. Robert Stillman: Well, but, but that was our vision. And, and at least it was my vision and Mike Levy and Mark Siegel may have had greater ones. We really want it to move from one lab to a bigger lab.
[00:10:07] Okay. One, a recovery room to a bigger recovery room and all those things took money and time and, and hiring new people and so on. So it was, you know, going from 150 cycles to 300, I mean, that's, you know, a hundred percent growth, but no one, I don't think I didn't envision that 10,000 cycles down the road from Integra man.
[00:10:28] And in fact, Integra that story with us was that. As we grew bigger, they became less valuable to us. I think they were good for small practices, medium practices, where you needed HR, where you needed it, where you needed a marketing, where you needed a whole variety of services such as that EMR.
[00:10:48] Okay. But as we grew bigger than we needed our own, you know, marketing as local, you know, they were in New York. And what did they know about the Washington market? You know, they, they were expert or, you know, experienced, but we need, we did it locally. So we were duplicative. We had our own HII HR, our own it, our own I mean, our it staff now is huge.
[00:11:10]We had our own marketing and so on and so forth, so we kind of outgrew them thanks to them. And I think that, I think that I, and I've said. Publicly, or at least with certainly within shady Grove, that it became a little bit of what have you done for us lately. Okay. They couldn't really keep up and that might've been internal to Integra med itself, you know, maybe personnel related.
[00:11:33] I really don't know the inner workings of why they couldn't keep up with us, but we were growing so quickly that it became limited. They still might've been very good for one, two, three, five member practices, but not for something at shady Grove. So we, I guess my
[00:11:49] Griffin Jones: guess is, especially at that time would have been that you were just such an outlier.
[00:11:53] There's only a few groups that are even in the ballpark of your site, especially maybe 10 years ago and or longer. And so. That's probably why it probably just didn't fit with their scale to scale at the same time.
[00:12:05] Dr. Robert Stillman: Yeah. Yeah. And the, their, their model was, if we do well, they do well, you know, which is always a good one.
[00:12:11] There were other consolidation efforts in, even in the Washington area back in, these was the 19 mid to late nineties, 1990s. And some of those failed including in Washington where they bought the practice and the physicians went on salary or small bonuses and so on and so forth. And the incentivization for the physicians collapsed.
[00:12:32] So I have my views on private equity and its effects on practice. Good. And at times not so good. And we chose the correct one. I was not involved with initially. Working with shady Grove, all working with Integra Med the Mark Segal and Mike, an art get the credit for that is well-deserved. But Integra Med was interested in my practice, the size of it, because I was the professor at that point, you know, and academics was still an important component to all this.
[00:13:09] And so I had my name and my practice to bring with me, and that's why I came on April 1st. And I think it was the 14th of April of that year. We, we signed the documents with Integra Med so it was really. I was just one of the cogs in that wheel, but an important one in, in getting the valuation that shady Grove wanted and needed.
[00:13:30] So you've painted
[00:13:31] Griffin Jones: a picture of the pre IVF REI field with microsurgery, then leaving the academic practice once IVF started to become profitable. So the early days of private practice then ventures with corporate groups, whether it be management or equity, like Integra Med, but also others. You're the medical director for a span of 20 years.
[00:13:53] And I'm making you give a highlight reel of two decades, but I'm making you do it now. And so when you think of, if you had to characterize to someone that was not familiar with fertility or coming into the field, how would you describe the, the changes that happened in the field in the two decades after that?
[00:14:17] Dr. Robert Stillman: Some of them, we're predicated on scientific advancements improvement in embryo culture, moving to blastocyst. putting sperm into the egg to improve fertilization, advent of male, fertility treatment and training and cryopreservation, both the changing the cryopreservation to be much, much, much more successful, utilizing a process called vitrification as opposed to slow freezing.
[00:14:46]And that also turned out to work for eggs, which is an important part of current and future. It turns out eggs, paradoxically are much less resilient than our embryos to cryopreservation. You think it might be the opposite, but it turns out no. So cryopreserving eggs was a big hurdle and the freezing by vitrification with, with good people doing it which is an important component is an important part of the field because egg freezing allows an expansion.
[00:15:13] One of the expansions into the consumer model which we can talk about regarding the future. So I think part of the was scientific advancement, and part of it was planning and working off the spoke and hub model. So in Washington, we had a lab and we built satellite offices around it to feed in for the egg retrievals and costs and lab intensive work.
[00:15:38]We then opened another lab in Philly, Baltimore, the same thing, and another lab in Philadelphia. We also had a model of that. We would go into cities that really had we fragmented weaker IVF programs. Okay. Of which we were one. Okay. And weaker academic centers with IVF. And I'm not talking about weak overall medical centers.
[00:16:02] I mean, GW is fine. Grit. Georgetown of course, had its own issues with Jesuit and couldn't do IVF Hopkins obviously is, you know, Philadelphia has world premier medical centers, but their IVF programs are notably, typically weaker. And therefore we could both utilize those and consolidate much more readily in there.
[00:16:25] And the art of war is one of my mantras. By Sun Tzu and not all of what Sun Tzu said involves you either have to make sure your supply lines are good, or you have to forage where you, where you are, but also that you don't necessarily pillage. Every place you take over, you can synergize with the medical centers there, you can synergize with other groups you can consolidate for their benefit, which turns out to be your own.
[00:16:55] And I think that's an relatively unique concept with medical or many businesses and taking over in other, in other areas, you don't have to be predatory. So there's much about the art of war that is less predatory than it might sound from, from the title. So those concepts of beneficent. And consolidation within an area that might be ripe, including areas where there's a high income level based on zip codes and low insurance areas as well, which is an unfortunate component of the success of fertility centers is there's not enough insurance for patients to afford it.
[00:17:33] Therefore they have more self pay, which we can get into and and scientific advancement. So I think all of those, again, you combine it, Mike Levy and Mark Seigal's you know, vision of, you know, how to play those roles. I think of myself as the, as the implementer, you know, as the doer, as the organizer, you know, as bringing the staff and everybody else into all that.
[00:17:58]And that's a good combination it turned out to be a good combination.
[00:18:03] Okay. So here's the skinny.
[00:18:04] Griffin Jones: Just as your fertility group has advantages over other groups, your competitors also possess advantages over your IVF center that you don't have access to yet. Now you can say their consolidation model won't work or their lab sucks, or their doctor's crazy, or that low cost model cuts quality or who would ever get their fertility testing done from a food truck.
[00:18:24] But many of them are onto something. If you're not maximizing your own natural strengths and adapting to what the, the new patient demographic is demanding, then they start to do more cycles where you are, get better rates from an insurance and vendors, take your patients. And even your staff. We work to maximize those competitive advantages because fertility bridge is the only creative and business development firm that exclusively subs specializes in the fertility field.
[00:18:50] We have an entire team of people who help fertility centers attract and retain the right patients and nothing else for a living so we can help only your competitors. And then they have an even bigger advantage or we can help you too. Our initial consulting engagement is the goal and competitive diagnostic.
[00:19:08] It's only five 97, and we equip your partners and leadership with the foundation to leverage your competitive strengths, not mimicking someone else and not let your competitors have an unfair advantage. There's no long-term commitment whatsoever, and there's a 100% money back guarantee. Send your manager to fertility bridge.com.
[00:19:28] Have them sign up for the goal and competitive diagnostic. And I will see you and your partners on zoom.
[00:19:34] There's consolidation and expansion happening and ways of being able to do it in a way where multiple parties are benefits sometimes, maybe not. But the this is all happening at a time where the RA lint REI landscape is shifting towards IVF.
[00:19:49] I think you and I talked about the bottleneck of REI's right now. When did that start to happen? When did you start to see that? Because when I talked to some of my friends that did fellowships in the late eighties, they said that REI 's we're coming out of fellowship and delivering babies. They weren't getting jobs in REI.
[00:20:07] And that's just very hard to picture, contrast that. Today and someone can make 250, 300,000 just about with any group, if they're coming out of fellowship because new docs are so in demand. And so when did that bottleneck issue start to happen across the country? Well,
[00:20:26] Dr. Robert Stillman: I like in some of it back to my, my historical arc than I did earlier in that when I left academics again, I was trained with a desire and, and love still for academics to be a chairman.
[00:20:41] And that's, that's why you went to Duke for OB GYN and Harvard for fellowship and so on it wasn't to go out and I mean, you could, but it wasn't necessarily go there with those laboratories. And then back then to NIH, to you know, have work-life balance. Yeah, it was to be a system professor I think I still may be the youngest person to be a tenured professor at GW.
[00:21:06]I don't know if that still holds and there's sorta this there's this rise that was anticipated. And then the next step was to become a chairman. Okay. Well, there was a whole cadre and I talked about this to friends of my age who were division directors, who instead of moving up to chairmanship left academics, because they found the same limitations of the academic world in with IVF small example.
[00:21:35] Okay. You have, you don't know whether you're running cycles with timed, egg retrieval, so you trigger. And 36 hours later, you have the egg retrieval. And once you trigger, you got to go or you lose the eggs and you don't know whether you're going to have one, two or 10 and shady Grove, maybe 20 or so a day.
[00:21:55] And you had to go first because you couldn't be at the end of the operating room list because you never know how long the operating room will go, because every surgery is delayed or emergencies. What have you. So you had to take over a operating room every day that you might not even use at the beginning, which is the coveted spot for surgeons.
[00:22:15] And that's a very difficult thing to accomplish in an academic setting. There's a lot of pressure and there were surgeons want the first heart surgeon, understandably. Okay. And to have your own space for operating room is even more precious. So you, you, we hit a ceiling and a whole bunch of us left.
[00:22:34] And that left a gap in the number of people who would then not only become division three or division directors with training fellows, but also would become chairman to champion fellowship programs and fellowship. So I think you lost a certain proportion, how many it's speculative, but you might've lost.
[00:22:53] You might have 60, 70, 80 fellowships now or 50 instead of 45 or 46. But I think that that was really, really part of it. And that helped create the bottleneck and the demand made that bottleneck more apparent if you didn't have a demand you know, 46 fellows a year would be fine. There was just a group of articles in the fertility and sterility.
[00:23:18] It might've been December, maybe November, December. I think it was that talked about whether we should modify fellowship training. Okay. Whether it should be bifurcated, whether she three years, two years, and what have you. And regardless of the, the outcome of that, it's really an interesting discussion that was had on the main pages and fertility and sterility and prescient to this discussion and January to this year, January, or was it March?
[00:23:45] I forget which there were the top, the first five articles in fertility and sterility were about the business of practice. The business of fertility practice, it talked all about EBITDA, swats, all sorts of things that you might not have expected to see, to show you how prominent it is. And it is in the field to have physicians try to be aware of the business aspects.
[00:24:13] Separate from the question you, you asked, but an interesting, I mean, it just dropped in the last month or so. What do you
[00:24:20] Griffin Jones: think some of those solutions are, is it, should there be double the number of fellowship programs? It sounds like if it weren't for that Exodus of REI is leaving academic practice, there might be double the number.
[00:24:34] Could we easily support that? Should there be 80 or so fellowship programs should fellowship programs be two years? What do you think?
[00:24:42] Dr. Robert Stillman: Yeah, well, I think 80 is, you know, is, is perhaps even a reach, but it, again, the whole thing is speculative. So but I think that the field could afford to incorporate more than 46.
[00:24:57] Okay. Because the bigger programs like us fertility and like the ovation and like a prelude, you know, a variety of other larger programs are going to continue to get bigger right now. They, Oh 8% of the programs have about 25% of the volume. And a majority of that is from probably five or six programs, and that's going to continue that it's just gonna, you know, Darwinian.
[00:25:28]And they'll always be practices that have you know, as Mark Siegel, put it, you know, the people want a paycheck and they want the work-life balance. They want to go home. They're not interested in a big and that's, that's terrific. They'll always be fellows for that, but there are going to be too few fellows, especially as individuals like myself, reach retirement age and are left.
[00:25:49] And that's a whole nother issue. That's important to talk about is the, how do you pay for the senior partners retirement and keep the junior partners and associates solvent and happy. But I think you can, you can certainly tolerate more fellowship programs. I don't think that's feasible to do.
[00:26:09]Can we talk a little
[00:26:10] Griffin Jones: bit about how they get established and maybe it's too elementary of a question for you, but I've often spoken to doctors who don't know. And so maybe it's good for people to understand that. How, how is it if university of Arizona wanted to start a new REI division in there, or at least a fellowship program in their hospital system, how does that happen?
[00:26:33] Dr. Robert Stillman: Yeah. There's all sorts of criteria that the American board of obstetrics and gynecology and ACCME now utilize to minimal standards for a fellowship program. And that includes volume of not only IVF, but also infertility patients of, of faculty training and faculty numbers of laboratory capabilities for research GWI utilized NIH is sort of a huge laboratory.
[00:26:59] We had labs on site, but they had a ability, the fellows had an ability to go window shopping at NIH in order to gain their research capabilities. So there are a very, very strict and, and difficult criteria to site visits interviews that take some time. To establish is just not, we'd like to do this.
[00:27:20] Let's see if we can fill in the gaps. The gaps have to be filled in prior to approval. And that's one of the rate limiting factors. And I don't, I personally don't recommend a dilution of that. I'd like, I think the solution might be some more, but at that high standard, that high level others argue that basically you're not doing surgery anymore.
[00:27:43] You can, you know, you're, you're doing IVF and, and egg retrievals and your, your skills are limited. And the research that you do is somewhat perfunctory. I think that would be a lost art as well, more than nostalgia, because you don't understand the laboratory without having been in it. So I think that there's some be some room, but not easily done from a cost perspective.
[00:28:10] Especially since the, the university of Arizona, I think was your example. It doesn't want to put the money into IVF labs, embryologist all the equipment and so on with a limited number of cycles that they might very well be able to do. So there's a real tension there.
[00:28:26] Griffin Jones: We're, we're sailing from we've covered a bit of the past.
[00:28:30] We were in present, we're starting to sail into the near future, and I want to stay on this topic because I've thought about, you know, there are, you know, there's like the, I think shady Grove is affiliated with two fellowship programs. Is, am I correct with that?
[00:28:43] Dr. Robert Stillman: Mainly the national national fellowship program in reproductive biology, the, the with NIH and Walter Reed, which is a great Affiliation.
[00:28:51] We pretty much do the, a lot of the clinical research wing for them because of our volume, but also the clinical training of the fellows. They get a good amount of that at Walter Reed, but our volume is so valuable to them. So it's a really a fine fellowship program, which of course is also a three-year interview.
[00:29:11] Right.
[00:29:12] You know? And so we're fortunate enough to have the pick of the litter. In, in fellows coming out. So it's a self fulfilling prophecy really is that we train fellows and we have a really great program towards partnership, which is another interesting thing to discuss if we have time. And therefore.
[00:29:30] We take a good number of the fellows for our program or offices. And that'll continue with us fertility compare a large proportion of fellows coming out of the fellowship each year. So
[00:29:43] Griffin Jones: I've been thinking what the application over there and there's groups, you know, prelude partly owns and operates least partly owns and operates the fertility division at NYU Llangollen.
[00:29:52] And so there, there's a number of these starting to happen and I've wondered, well, what could the application being as you talk about one of the deterrents for starting a new REI division or a new REI fellowship program is the cost. It could, could be the, it could be an inhibitor for the universities and health systems doing that.
[00:30:11] And if they had the opportunity to partner with some of these groups, could that be a
[00:30:15] Dr. Robert Stillman: solution? Absolutely. And I have a history of that. I was a consultant to Beth Israel hospital. A good friend of mine was the chairman there and I put them together with Boston IVF. Okay. And one of the things I had recommended, which we then modeled it, shady Grove later was bringing on a research scientist to help with the research the clinicians wanted to do.
[00:30:39] And part of the idea of utilizing Boston IVF volume was to do clinical research. And both because it's good for the field and academics, but it also as a huge ROI on that. And that was something we realized that shady Grove later on. And so I suggested that you don't want your physicians to be out of their lane or capabilities.
[00:30:59] You want them to be generating like Boston IVF. You wanted them to be generating the volume of patients and the success rates and so on and so forth. But so you needed a research scientist with its overhead and team to utilize that research and turn it into publications and turn it into the field and shady Grove.
[00:31:16] We did exactly the same thing. When I came on board, we brought on a research scientist. Now we have a whole team of research team. And again, there's a huge ROI on that. You get known in the field, you get referrals from across you, it you get international recognition and patients from cross border reproductive care, besides giving back to the field I was fortunate enough.
[00:31:39] To have had a career, as we talked about that span both. So I've been there, done that with the academics and now with private practice, but say Mike Levy would have been superb academician and he always kind of missed the idea of the research component of it. He was too valuable, gratefully enough.
[00:31:57] He went into private practice, but so he we satisfy some of those goals to give back to the, to the field really altruistically, you know, because we, we felt we had a responsibility with that volume, but also there was a, an untapped ROI on that. So we also did that with Tampa. Okay. We opened the clinic there and took some of the people who were on the faculty.
[00:32:21] And we, we try to make, instead of the art of war, as I mentioned earlier, instead of just competing with them, we tried to bring them on and synergize with them. And it, it helps if the, the academic center doesn't have to do the IVF onsite anymore. So the reason, as I stated earlier, for logistics of the operating room costs and so on and so forth, so they get the training program.
[00:32:47] Okay. Of infertility with expanded volume as well from the private practice. And they don't have to have, if they don't want to, they don't have to have the costs that having the IVF lab, the embryologist you know, the space and so on and so forth. So it can be a real synergy. And the NYU Langone is a different story.
[00:33:04] Of course. And, and another example of academics in private practice would be Cornell. You know, they've managed, but that's New York, you know, and, and those are Sumo wrestlers banging into each other. As opposed to the model that I said was Washington, Baltimore, Philadelphia, where we kind of aggregated dis you know small disparate practices.
[00:33:26] There, there, there there's no one dominant player because they're just also big and powerful.
[00:33:31] That makes
[00:33:32] Griffin Jones: sense, given the market too. But the, as you're describing this potential for a. Public and and private or not public necessarily, but health system, academic and private partnership. It also seems that it could solve for a paradoxal effect that otherwise could happen where let's say, we, I know 60 might be a reach number.
[00:33:53] You might not want to dilute it to, but I'm just using 60 as an example of getting to 60 fellowship programs as opposed to 46. Well, then at the very least we would need 14 more division chiefs. We would need, we would need that much more faculty that would put a further or burden on the supply that we have to meet the demand in the fertility field right now.
[00:34:14] And that burden could be lightened by partnering with groups that either already exist or already have three sources so that you might not have to take as many REi's out of the field to train the, and additional people coming
[00:34:30] Dr. Robert Stillman: in.
[00:34:30] You do need the philosophy. Which is not universal of that synergy. And I think that's one of the things I brought was I think that that synergy between academics and private practice is the ideal starting point that may not come to fruition in a particular market, but is the place to start.
[00:34:57] Okay. As well as again, not being predatory is taking work or trying to work with practices and bring them on that might be open to partnerships as opposed to just, you know, coming in and survival of the fittest, you know, and, and burn the burn, the rest of the house down. So again, that doesn't work all the time, but if that's the starting point that you have you know, that it can work in a much more frequently.
[00:35:23] So we've come out
[00:35:26] Let me finish to answer your question more directly there's but by the time you grow to 60 fellowship programs as a truly hypothetical, but even if you could start today and said, and ABOG said, American board of such an united on this, this is our goal. I don't know if they're saying that at all, but it would take a while to do that.
[00:35:50] And there's a demand for volume that is already there, that isn't going to wait for the several years to get up to 60. And that volume is related to not only some fertility benefits both state insurance, as well as consumer driven insurance groups. Progeny and so on, but also consumer non infertility demand, which is really going to be driving the field and freezing LGBTQ cross border reproductive care, continuing or getting back genetic testing for non infertile people.
[00:36:25] You'll, you'll be at Gatica soon, you know, where you're picking embryos and for much more than genetic breaks and, and too many chromosomes aneuploidy versus euploid. So all of those are going to I think dramatically increase the volume of potential patients, clients for fertility practices and that REI is won't be able to meet that.
[00:36:51] And we did this. Early on with shady Grove. We with the nurse clinicians doing a R H S GS and IUI and ultrasounds we brought on urologists that we had previously farmed that stuff. We still farm out our GYN surgery, but I think the next way it may be bringing on GYN is to do surgery, including agretriums and so on.
[00:37:12] And leaving a REI is to be a much more narrowed focus of cycle monitoring and patient management, both from telemedicine, artificial intelligence and, and genetic advancement.
[00:37:28] Griffin Jones: So now we're sailing into the future. You mentioned Gatica and we've talked about how we got here. What are some of the ways to meet the demand and we could possibly ABOG could possibly start to help build more fellowship programs, but even that would take a long time that would only satisfy some of the demand.
[00:37:49] One thing that's happening right now is I used to hear a lot of people except for Dr. Kilts. And this isn't private conversation with Dr. Kilz because he's been on the show twice. And I invite people to go listen to those episodes where he is insisted for a long time that either other OB GYN physicians or advanced providers can be doing a lot of what many REI's are doing right now.
[00:38:09] And when I I've only been in the field seven years, Bob people used to poopoo that idea a lot, and I hear a lot less resistance to it. Now, is that something that's inevitable
[00:38:22] Dr. Robert Stillman: Yes. I, think it is because of the supply and demand. Again, these are highly capable, you know, well-trained people and some of the stuff we do if we can turn the volume down, isn't so hard, you can turn the volume back, back up, you know?
[00:38:40]And, and that's easy to say, you know you know, from somebody who's done it for so long, but it really, really is true. And so therefore you need to supply that you know, the, to meet the demand and as the demand increases the supply will be greater, including when people retire. You know, and want their way out.
[00:38:59]How will you, how will you be able to fill that? .
[00:39:02] Griffin Jones: I
[00:39:02] Dr. Robert Stillman: think inevitable that we will have additional personnel to do a fair amount of what reproductive endocrinologists do.
[00:39:11]Now, including HSGs, although we have nurse clinicians doing that you know, already IUI is monitoring egg retrievals and the reproductive endocrinologist will be an in a somewhat supervisory, overseer role as well as interviews and telemedicine and so on and so forth. And I see that as an inevitable means by which to help the supply,
[00:39:38] Griffin Jones: What needs needs to happen in order for the quality of care and the advancement of treatment to remain at the same level, because otherwise we would be saying, well, I guess you don't need a three-year fellowship after all.
[00:39:52] I guess you just guess you just wasted those three years after residency and either that's true or it isn't, and there are other things that we need to account for. As OB GYN, nurse practitioners and PAs are trained to do those things that you mentioned,
[00:40:08] Dr. Robert Stillman: right?
[00:40:09] Well it might get better not worse.
[00:40:11]Depending on the individual physician, you know, there's a spectrum of reproductive endocrinologists, and there's a spectrum of gynecologists who haven't been trained as aggressive, not aggressively as, as widely, and bet those two spectrums overlap, but that isn't the main point. The idea is that there'll be a narrower work that the reproductive endocrinologist will be responsible for protocols m onitoring decisions.
[00:40:45]Some of that's also going to be artificial intelligence not only in the laboratory with the selection of embryos, but also in IVF protocols.
[00:40:54] So you'll put in age BMI, AMH and FSH, antral follicle count and so on and so forth. The antral follicle count may very well have been done by an AI driven ultrasound machine, even perhaps remotely at the patient's home. And the, you put that in and the pro the protocol will be come out of the artificial intelligence, big data set.
[00:41:18] Okay. So some of that decision-making from the reproductive endocrinologist will be taken over aided by enhanced by AI. And therefore some of that will become less necessary to have the highest level of reproductive endocrinologist. I still think that they will be the forefront of care for patients.
[00:41:40]And interface with patients, but I think there are a number of tasks that just like we do now. We farmed out our myomectomy or fibroid surgery or tubal surgery, which again, when that's done our ectopic surgery, that's all now done by gynecologists or even oncologists who are anxious to do more surgeries.
[00:42:01] We can bring that in, in house as well. And, and even, you know, get reimbursed for it. So I think that they'll always be the reproductive endocrinologist much more fitting the, the volume that there are you know, for that.
[00:42:17]Griffin Jones: So what's the daily responsibility of the REI going to look like in 20 years, Bob, are were we talking about a doc that's in front of a screen, the size like Tom cruise in minority report where he's just pulling each, you know, he's supervising hundreds of case loads at a time on a giant screen.
[00:42:35] And, and there are just divisions of teams and processes that are allocated to each pillar of cases. Is that what
[00:42:44] Dr. Robert Stillman: it's going to look like?
[00:42:45] Well, 20, 20 years is a really long time, but it might, but I, I, I see one patient at a time on the screen, you know and again, with both telemedicine, which the pandemic has pushed forward quite a bit regarding the comfort level of that, but also that's going to continue.
[00:43:05] I think a home monitoring will help some. Especially with populations of individuals, not patients who don't want to come to the clinic who don't want to be with the sick people, if you will. A good example of that is we have another academic downfall is that often the space you had for waiting room for your infertile patients was also the waiting room for the obstetrical patients because it's an OB GYN department.
[00:43:33] So say what you will about that. Patients didn't really want to mix that way. So you have a woman who wants egg freezing or is there for genetic analysis of embryos prior to putting them back. But isn't infertile. The, they may feel less comfortable coming into the clinic every day or a more and more amenable to a remote monitoring.
[00:43:53]It's also helpful for people at work, you know, to not have to come into the clinic every day. So it's not only the consumers. So I think all of that's going to play a role. And some automation in the laboratory with AI. I'm not sure about the embryologist in a box concept yet with doing the insemination and culturing and so on.
[00:44:13]I don't know if that's gonna make it, but the, the it's already being talked about as being an acceptable product. So 20 years, I don't know, I give it five years and there'll be the need for more ancillary personnel. I'll give you a little background. Art Sagoskin superb infertility specialist is not a reproductive endocrinologist.
[00:44:38]He started the fertility center. With another gynecologist and then brought Mike Le'Veon and then it became the shady Grove fertility center and then one one of the other people left and then I joined Mike and art. But so there's a good example of now he's had 20 something years experience almost 30 years of experience at it, but he was just a very fine surgeon, a laparoscopic surgeon and all sorts of experience.
[00:45:04] And he doesn't do that anymore either. But shady Grove was started with a non-REI go figure that
[00:45:11] There are still a few
[00:45:12] Griffin Jones: of those folks left and, and I can think of one that we work with that is really great. A really great fertility doctor, but same thing. Didn't do a three-year REI fellowship that was a while ago.
[00:45:25] And so I think that was those folks were grandfathered in any of them. And now it's coming back to that.
[00:45:33]Dr. Robert Stillman: Right? I think that, I think from my bias, if you will from academics and the REI training and training of fellows, that there is real value in the depth of the fellowship training to making them superb clinicians how necessary that is, especially at certain tasks is what I think volume will alter.
[00:46:01] I don't want to minimize the importance of the reproductive endocrine academic training. But I don't think it's an absolute necessity for everything fertility.
[00:46:11] Griffin Jones: How should it alter the program?
[00:46:16] Dr. Robert Stillman: How should as volumes
[00:46:18] Griffin Jones: alter the needs as volumes alter, what REI's will actually be doing? How should that alter the curriculum of a training program?
[00:46:31] Dr. Robert Stillman: Well, I'm still in favor of the three year program. I think some more of that could be fertility based and lab and IVF laboratory based rather than some of the other pediatric menopausal work that covers it. So I don't know if you could have tracks, but I'm interested in. Being a fertility specialist.
[00:46:57] I'm interested in staying in academics and dealing with menopause and birth control. And I'm interested in pediatric reproductive. And you know, so maybe there are tracks that can allow more time focused as opposed to everybody doing the same three years.
[00:47:17]Griffin Jones: I had this conversation about, well, it must have been right before COVID because it was in person and was with a younger doc about my age and a really good doctor.
[00:47:28] And we were talking about this dynamic of many of the responsibilities being shifted to other OB-GYNs or advanced providers. And he's thought about it. Wasn't like I brought this entire perspective to him for the first time, but he, he thought like, what are we going to be doing in 20? Is my job going to be irrelevant?
[00:47:51] And I thought, no way is your, your job going to be your you're going to be managing so many more cases. Right. Right. What else are they going to be? You know, for those thinking, well, if I'm not going to be doing the retrievals and I'm not going to be doing IUI's am I going to be irrelevant in, in a decade or three?
[00:48:10]How would you assuage their concerns?
[00:48:13]Dr. Robert Stillman: Well, I think that they don't have to not do the retrievals. I think there's just, instead of having five, seven reproductive endocrinologists doing one day a week you have you do your day a week, but that's three or four reproductive endocrinologists and the other three days are well trained surgical gynecologist.
[00:48:33]So it's not, I don't think it's an either or I'm kind of more worried about who'll be controlling the clinic in which they're working. Is it a private equity ownership or is it a, you know, is it, are physicians still the primary managing partners to make those decisions? Why does that matter?
[00:48:56] Because I think that the physicians have an ROI in mind, but it isn't the primary focus or shouldn't it, it should, it can't be. Lack of knowledge as the fertility and sterility, five articles points out and Mark's training us at shady Grove inhibitor and other important dynamics.
[00:49:16] But if you have complete ownership of a fertility practice, then people talk about, I keep hearing in consultations three, five, seven, it's like a new word. You know, that they're going to be out. Private equity would be out in three, five, seven years. I said, I hadn't, I didn't know that word three, five, seven.
[00:49:39] And that's, I think a dangerous is not the right word word, but is a difficult concept to make a longer term and much bigger ROI. Integra Med for instance, was an MSO, but that was a 25 year contract, you know, That's putting themselves and the clinic on the same track. If you, win we, when we, win you win for 25 years, not three, five, seven now.
[00:50:07] Griffin Jones: No, but as you pointed out, you outgrew Integra Med at that point,
[00:50:11] Yeah,
[00:50:11] Dr. Robert Stillman: but we're the only, pretty much the only ones who did that, you know, of the 20 integral med programs. I forget exactly how many we were just about the only one who outgrew it. So there's still a role for that. But if, if again a clinic in Washington, which was bigger than us back in 97 they lasted about three years before they completely imploded.
[00:50:34]We took one of their physicians after that, actually a couple of their physicians after that. Because their model that they joined, I don't know what they got out of it, you know, money. And I don't know, I don't have a clue of that, but the model was basically, they were on salary. And the incentive to grow, just not, and maybe the clinic, the, I think it was FICOR or whatever the private equity got out of it.
[00:50:58] Maybe they were happy and maybe they sold it to somebody else. I don't know, but I don't see that as being a the best model regarding equity position in, in the fertility market, I may be biased, but importantly, I think that most physicians who are going to be making the decision as to who to go with would have a similar bias.
[00:51:23]Griffin Jones: You've given us so much to think about with the field, from how it started to how we got to a bottleneck capacity is supply and demand start to , totally separate from each other, to what the future will look like with artificial intelligence, with at home testing and and different ways of training other providers to be able to do things in the field.
[00:51:45] How do you want, want to conclude with what you see happening in the, in the next five years? And maybe we say what's your best case scenario. If, if if a magic wand was waved in and the best things in your mind happened in the next five years, what would that look like? And then what would be the cautionary tale that you'd leave us with?
[00:52:03]Dr. Robert Stillman: I think the future will be more consolidation. Bigger groups will get bigger. There will still be some. Mom and pop shops. And I don't say that in a pejorative way. I think they're great, including people who want to, you know, have a salary and go home and work life balance. They're going to be more and more difficult to recruit to the partners that exit and the bigger groups will have the capital to grow and utilize the expenses that go with artificial intelligence and take care of the growing demand, whether it be much greater growth from consumer non infertility patients combined with a steady increase in fertility infertility patient use the cautionary tale is three, five, seven is equity ownership and a flip and that will hurt patients.
[00:52:55] Ultimately her practices as well and be detrimental to, to the field. And I worry about the the FOMO, you know, and everybody going over the cliff exacerbated by more and more retirements. So I think that's the cautionary tale as you know, as I see it, but hopefully we'll be able to treat through advances in technology, treat a whole lot more people including in fertile patients,
[00:53:22] Griffin Jones: Dr.
[00:53:22] Stillman, Bob, thank you very much for coming on inside reproductive health.
[00:53:26] Dr. Robert Stillman: It's a pleasure. And thanks for doing what you do at fertility bridge.
[00:53:31] You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action, to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society, visit www.fertilitybridge.com to begin the first piece of the fertility marketing system, the goal and competitive diagnostic.
[00:53:51] Thank you for listening to inside reproductive health.