This week on Inside Reproductive Health, Griffin brings Dr. Daniel Kaser on the show to chat about the growth of the LGBTQ+ patients and third-party care. What it means to be inclusive to this group may surprise you! Little things, like patient intake forms, can make a huge impact on your ability to serve all populations.
Listen in to the full episode to hear:
How 20% of Dr. Kaser’s patients are LGBTQ+ and how he is serving them well.
Why REIs could potentially service only LGBTQ+ patients in some markets.
Griffin drag Dr. Kaser into the battle about board certification and access to care.
How state laws were relevant to Dr. Kaser’s practice location choice.
How you might be wrongfully segmenting patients at intake.
Book Links :
“How to be An Anti-racist” by Ibram X. Kendi
Dr. Kasers info:
Transcript
[00:01:00] Griffin Jones: We're talking about the growth of third-party and particularly LGBTQ plus patients as a practice area today on the show. My guest is Dr. Daniel Kaser from RMA Northern California in the Bay Area. Dr. Kaser talks about how he started his career in choosing even which state he moved to based on. The laws that were more accommodating to he and his husband at that time.
And then where they ended up moving to further that practice in the bay area, he did his fellowship at Brigham and women's he joined RMA of New Jersey in 2014. I want to say and then has recently been at the Bay Area and we talk about what is needed to. A third party program to serve LGBTQ plus patients access to care, and some things that surprised me about segmenting or not the patient populations within that broader patient population.
So I hope you enjoy today's show with Dr. Dan.
Dr. Kaser Dan, welcome to inside reproductive health. Thanks for having me great to be here with you. Good to have you on. We were saying before we started that it's like we've known each other.
This is the first time we've actually spoken face to face, so to speak via video. And when we were talking, you mentioned something that I thought would be interesting for the intro. One of the reasons why I wanted to have you on was taught to talk about serving LGBTQ plus population as a practice area and.
It was also, which is what you do now in the Bbay Aarea, but it's also part of the reason why you chose either your fellowship program or the first practice you worked with. Can you talk more about that?
[00:02:51] Dr. Daniel Kaser: Yeah, absolutely. So I ultimately went into reproductive medicine and in fertility specifically to be able to help my own community in terms of other LGBTQ patients.
I knew at the time that for me to have a family, this was the path that I personally would be taking. And so I became interested in IVF early on in medical school, actually through, introduction to reproductive physiology by some really great professors and then had done some away rotations, even as a med student on like the infertility unit.
So I fell in love very early with cruel. The actual profession, but I was commenting that reflecting back that my husband and I got married in 2009 in New Hampshire. We met my husband. Dana is a physician as well. And we met in medical school. And at the time in 2009, New Hampshire was actually one of the only states in the country that recognized same-sex marriage.
And so what felt to be a very new kind of cutting edge thing now, fortunately it almost seems commonplace in terms of two men or two women getting married, but we had a church service and had a reception on campus and surrounded by dear, dear friends and family members.
And this was six years, I guess, before the Supreme Ccourt ruling to legalize gay marriage across the country. And so in choosing frankly where I did my post-graduate residency and fellowship training, we look to states at the time that allowed gay marriage and recognized our marriage.
And we ended up moving to Boston, Massachusetts, where I did OB GYN residency, and then stayed for fellowship training. And then at the end of my fellowship in 2016, had been looking for my first position out, outside of kind of the training here and still was looking for states that were inclusive in terms of marriage law.
And so I signed, I came to RMA for a number of reasons, but in 2014 is when I initially signed, signed contracts to come on. And at that point it was still like a year before the Supreme Ccourt rule. And so truly like if you look back at that, the places that I went to medical school, residency fellowship, even my first job it's informed by like policy and where I could frankly have rights recognized at the time.
And felt welcome and celebrated. So unfortunately here in 2022, it feels like a lifetime ago that there were places in the U S that did not recognize a relationship like my husband and mine. It's pretty amazing to reflect back, like even in the short 10 to 15 years, How far we've come along, frankly.
[00:05:55] Griffin Jones: So that was part of how you chose the state that you ended up bad. Well, one of where you got married in New Hampshire in 2009, but then to practice in 2014 at at RMAarmy and sorry, that was, that was , your fellowship was in, was in Massachusetts. Your fellowship was in Boston and then your, and then, so it was your first job after fellowship was in New Jersey.
[00:06:16] Dr. Daniel Kaser: Brand spanking new, like infertility fellow just finished and then signed on to join RMA of New Jersey and yeah, and moved to actually Philadelphia. At the time and the practices helping open up in Southern New Jersey for RMA was like just across the Delaware river. So I would commute across, across state line and would go to work each day. But I was at at RMAarmy New Jersey for a few years and really help them develop LGBTQ kind of care.
[00:06:48] Griffin Jones: Why that practice though, Dan? So I'm following why you ended up in New Jersey, your interest in. REI in particularly this application where I started pretty early, you said you were starting to figure it out and med school that this directly impacts my community directly impacts me. And a lot of people don't come to that realization so early or at least not, for their subspecialty often they don't even, , come to their specialty until a little bit later.
And you notice it pretty early on. So, but what about the practice continued to follow that line for you?
[00:07:28] Dr. Daniel Kaser: For me a couple opportunities that at RMA that attracted me there, frankly one was to help open a new IVF center for them and in south Jersey. And so a dear friend and partner Jason Franasiakfor Phasiac and I helped establish an open it a new center there for, for RMA to kind of anchor the south which was an amazing opportunity directly out of fellowship to be involved in everything from architectural plans to kind of operation.
And management of the decisions, large decisions down to the various tiny finishes and things. So that was a compelling reason right out of fellowship to come to RMA. And then secondly, I had the opportunity to, based on my interests egg donation and teargas to help lead their third-party program.
And so truly, a year out of fellowship I had had taken on for, for the practice of $25 or so the director of the third party role, which feel fortunate of that opportunity. And frankly had really great mentorship there in New Jersey to have helped me kind of establish myself in that as not only an interest of mine, but something that, I have expertise in and, and I'm excited to be able to offer patients, frankly.
So it was the was really a great, great opportunity at the right time.
[00:08:52] Griffin Jones: What was it like building out the LGBTQ plus practice area, part of the third party program, practice area. So you've got a LGBTQ plus focus as a part of third party. What was involved in building that out?
[00:09:09] Dr. Daniel Kaser: Yeah, it's in looking back at it, there was already, , program there.
And frankly, since the practice it opened in 1999 that been, had opened doors and had been inclusive to patients of any sexual orientation or identity. But I think it was more systematically and kind of comprehensively thinking about this as like a sector of care that is growing and that we need to have a more COVID program. And so, the care is in terms of what actually is being done at donation and surrogacy. It's not unique to gay men, for example. But some the messaging and, and frankly some of the like content online and how you interact with patients and what patients expect it is unique.
And so, in working with the third party team there it was helping to grow, a few aspects of, of the program specifically like advocacy an online presence. For, LGBTQ care both, on websites and social media, and then also frankly, getting involved in research this area as well.
So it, I think went from, offering these services to try to kind of put together a program, frankly, where it is not only taking care of patients, but also the broader community.
So at RMA help helping to establish really a comprehensive program for LGBTQ patients. We took efforts to develop the advocacy role, frankly, as physicians and healthcare professionals, thinking about this community and what we could potentially offer.
And at the time, surrogacy was illegal and in New York. And so basically like serve to the lobby mostly through like newspaper editorials and writing letters to senators and, and and representatives in New York. Just frankly, how important this type of care is for the community.
We also took on some research projects specifically to evaluate, best practices for for LGBTQ patients, one we published in, a major journal looking at the role of one versus two inseminations for single women and also lesbian couples using donors from, to try to establish whether, a single IUI was, was sufficient or if a second IUI, added benefit and did not in that study did not seem to.
And then we also published the experience that RMA has with over some 10 to 12 years of several hundred men who had gone through the egg donation and surrogacy program to become fathers really just talking about access to care. And it was a web-based survey that we distributed to former patients and current patients who, who were undergoing this treatment to ask them questions in terms of how are they paying for this treatment is insurance covering it?
Are they having to travel from out of state to be able to access this? And similarly published this and, we're surprised to learn, frankly that something like 40 or 45% of men who we were seeing like didn't have the opportunity to do the type of treatment that we were offering them within their own state.
Some of that reflects just the kind of broad catchment area that a practice like RMI has and that, people come from out of, out of town, out of state, but, but not all in that, some, a good number of programs either. Don't have a lot of experience in, this type of care or choose not to develop it.
And we were hoping to, by thinking about this as a more cohesive program hoping to help establish it as, a destination spot for gay men and women, frankly, where they would feel welcome, they would see team members that were in the community. And would frankly feel celebrated undergo in this type of treatment?
I think, in working in some, I now I'm in practicing in San Francisco, still with RMA. But in San Francisco, I would say roughly one out of five individuals or couples that I see is, is LGBTQ or a single and doing this with donor gametes. So it's definitely, I have somewhat of a biased perspective, but it's a growing part of fertility care.
And these, patients have choice frankly, and where they go and in meeting with them, I think what's unique about, about the consult that you do is that they're not typically, haven't struggled with years of, of infertility or miscarriage or pregnancy loss. And two are coming from that very initial consult in addition a different spot in their life.
And some of them may never have, have thought that they were going to have kids and the decision to, to like set up that initial appointment is a large one in that it's like, they're there consciously, like for the first time undergoing the steps that are needed to, to have a child and to start their family , the, the pregnancy rates that we can offer through, through this type of treatment, they're really the best that you can do.
And fertility, in terms of in particular egg donation and surrogacy. So it's never, never a guarantee. It's never a hundred percent certain, but they're overall very excellent clinical outcomes. And I think the tone of the consult from day one is it's frankly helping them celebrate that choice that they're, that they're starting their family and helping to reinforce that choice, that they're making a good decision and, and educate them about, about the process, not only the fertility treatment, but, connecting with other, other couples or individuals who have who've done this and have young families.
[00:15:27] Griffin Jones: By doing that you're validating that they came to the right place to, and you mentioned earlier that, that they have a choice in where they go. And it does seem to, to me that a handful of doctors or a handful of practices see far more than the proportional representation of same-sex couples and many see far fewer perhaps because many see far fewer.
And it reminds me of, of someone called me a couple of years ago, and they really wanted to target same-sex couples and particularly same-sex male couples. And they were just, even before we even got to needs or shit, well, how much will it cost? How much it will cost and as a lot, because you haven't done anything yet.
And all you're doing right now is coming and saying, I just want more of these dollar signs coming into my practice. Meanwhile, there are a numb, there are some people in the, in the country, doctors and practices that have really been. Practice areas for, for that. So can you talk about, I mean, now that you're in the bay area I'm guessing maybe a lot of those folks are, are local, but maybe I'm wrong on how far people traveling for.
[00:16:44] Dr. Daniel Kaser: Yeah, it's an interesting question. I would say most are within California currently, and particularly in the Bbay Aarea, there's a large community. And it's becoming more and more common for men to, to have not only one kid, but come back for a second child. I would say right now it's probably 10% of the of the patients that I see, like specifically for egg donation and surrogacy are from outside of this state.
But just in the last six to 12 months, I think the word is getting out. I'm starting to see more and more international couples that are, looking for care as well. So I think that's frankly, perspective in like being a gay man with a child through egg donation and surrogacy.
It's something that I'm passionate about in helping other, other couples go, go through the process. And I think offer some additional kind of context to the, the decisions that have to be made along the way too so.
[00:17:47] Griffin Jones: You have the rapport that the personal rapport, because of your own experience, you have the advocacy that you've been a part of the he talked about the messaging as a part of that, but you alluded to some, some systems that at one point earlier in the conversation, what were some of the systems that you had to update to better serve LGBTQ+ patients?
[00:18:10] Dr. Daniel Kaser: Yeah, it's really fascinating to like, sit and think about this about like, and some of it happened organically and other was, more thought out the fertility care, frankly, really grew in the nineties and early two thousands.
And a lot of the practices that, that formed at that time, w either weren't offering this treatment or weren't offering this treatment well. And so a lot of the systems were, were built, frankly, ,around straight couples only. And, had some inherent biases kind of baked into them, not intentionally in my opinion, but truly just reflective of the care that, the type of patient that they were caring for and, and what a family looked like in the nineties
and in early two thousands.
[00:19:00] Griffin Jones: What are some examples?
[00:19:02] Dr. Daniel Kaser: Yeah.
One is just representation, frankly, online in terms of the content that's on, on websites. There was a survey that was done in, in 2017 that was published in fertility and sterility that looked at this and they looked at all start reporting members at the time and they truly just looked at their websites to determine whether or not they had content for LGBT patients are not, and it was actually just 53% of the time that the 300 plus start clinics had had any content whatsoever for gay couples. I think if you did that study now, if I had to guess it'd probably be more like 75 or 80% but it's definitely still not a hundred percent.
So just truly, even like having content on your website and like appropriate information, there is one example, another example is intake, frankly like intake forms and how patients and their partners report their medical history and, and basic things like sexual orientation and gender identity, a lot of.
A lot of practices ,are still there intake forms are gendered and assume that they have assume you have a partner. And so, , one of the structural things that that I helped do kind of early on in helping establish this program is just frankly, the look with a critical eye at the forms that, that patients sign and submit on establishing like a new patient.
Everything from the non-discrimination policy, making sure that it had, LGBTQ kind of identifiers in there to frankly collecting sexual orientation at the initial call and preferred pronouns and intake forms that, that we started with were interestingly, they were kind of custom-made for different kind of types of treatment.
Then, so far as like a heterosexual couple, there is a separate form for a transgender patient. There is a separate form for a lesbian couple. And we thought at the time it felt like the right thing to do as you could really tailor the questions that you're asking to that particular type of patient.
And then through frankly, patient feedback just inexperience in working with different couples. It actually, and not surprisingly, it became clear. Like these separate forms, don't always capture the broad range of experiences people have and the types of patients and frankly ways that they can do treatment.
So it was hard to kind of put, put people into a box of a form. And so we actually like just generalized one form and went back to one, an intake form, but made it very, very inclusive and so.
[00:21:57] Griffin Jones: So that's interesting to me because the nature of sort of everything is to become more fragmented, right? More, more specific, more specialized start with three TV channels than we have with cable and have a hundred.
And then we'd go to the internet and we have infinite. And so one would have thought, okay, we're starting from, we're back at the time where it was just partnered male-female couples. And then we started to serve maybe gay women. Then we started serve gay men. And now transgender couples and others.
And so I would have made the assumption that you've you further segment and, your experience taught you otherwise.
[00:22:31] Dr. Daniel Kaser: Yeah. And that, I mean, that is exactly right. And that, that was our initial consideration as well. It just didn't seem to work as well as a single form did and just making sure the language and the form had had space and had range to cater to the different patients that we care for another example of this is in terms of like looking at kind of structural things about a program is the medical record and how, these episodes are documented by the clinical staff and whether or not you can, query whether, sex, sexual orientation or partner status in the medical record.
So you can, do research. You can't change anything or can't look at whether an effect is, or an intervention is improving anything. If you're not measuring that. So true. The first, like one of the first things is like we have to collect sexual orientation and for everyone coming through the door and like you, interestingly, it's like the first time that this was being counted, that like gay gay men and women were being counted in the practice.
And it's crazy to think about it, but it wasn't until the 20, 20 census actually in the United States, that sexual orientation for the first time was like included in the 20, 20 census. So like also, now being counted in the us census as well. And with the hope to like that, that can, by measuring it, you can, address gaps and, figure out where resources are needed, if you can do research projects.
So in any event, the medical record just is truly being able to. To count how many consults you're doing of this type is important. And then also other things like, allowing nicknaming to happen, where you can assign like a nickname for a patient that's in particularly important for like our trans community in that a lot of trans men and women don't like identify with their birth name.
And they actually referred to it as their dead name, like their name assigned at birth. And so they go by like a nickname. And so whether or not your EMR can capture and can assign like nicknames as the preferred names. We looked at consent forms to make sure that consent forms weren't gendered and assumed a partner status. So I think that it's looking with a critical eye at every kind of interaction that a patient and partner might have from the initial call to the consult, with the physician day-to-day interactions with our front desk staff even working with financial counselors and, and the, the program and having options for that are inclusive for financing this frankly there, there are some, some outside organizations that allow you to take out quite a, a large sum that, that have money that you can finance at a low interest rate.
So just frankly, like having information available about how to make this a feasible thing to undertake, I think is important. And, being in network with some non traditional payers is not the right word, but the, the major payers, like historically in fertility care are the major players outside of, fertility as well the Blues and Aetna and so on. But, some of these groups and I have no relationship with any of them, but Progeny and Kara and Maybin, some of these payers are, are, are doing frankly really revolutionary things for LGBTQ care in that they offer egg donation and surrogacy benefits, but they don't, they are not concern whatsoever about a patient's sexual orientation. So one of the biggest ironies in my career as like a fertility doctor start like going to set out to start, my family is at the time I was in practice, in New Jersey, a mandated state, and truly had really amazing fertility benefits through a major payer that covered everything in IVF, they cover the egg donation and even covered like a reimbursement for, for surrogacy. But the irony is that based on, who I was married to I actually didn't have access to any of those benefits in a mandated state, as a fertility doctor with really, really comprehensive plan. And that doesn't sit with you well, when, when you experienced something like that firsthand and fortunately, there are other ways to make that journey feasible.
But in looking and looking back at it, there are a lot of a lot of insurance companies, frankly, in my opinion, are discriminatory. I'm still against, against our community in, in helping establish families. And they have a very I think outdated definition of infertility and like who, who has access to this type of care and that they're defining sexual intercourse between a man and a woman not leading to conception after six or 12 months.
So, for one in 20 individuals in the U S now that's not a reality. And so even if you don't choose to use it benefits. I think it's important to like be included to have the option as you're paying into that. So these other payers like progeny and so on just truly by not defining who can access their benefits has really revolutionized the number of patients that we're seeing and also like how many people are frankly interested in, in, in starting, starting their family. It's not surprising to me when you like lower barriers to certain things, more people come and more the interest is broader than maybe initially expected. So think over the next 10 to 15 years, we're going to see a tremendous Increase in the number of gay patients that we're caring for. And I think really important to like, make ensure that your, your practice is, is up to date and contemporary with, this type of consolidate and this type of care.
[00:28:52] Griffin Jones: I want to ask you about where you see the trend going, because you're managing third-party and LGBTQ plus patients are a part of that.
And you said one, you said about one out of five patients is LGBTQ plus. And so do you see within that, you mentioned you think it's going to grow in the next 15 years? Are we already starting to see some doctors that it is there enough demand now that in a large city, that one doctor could say, well, of course I see anybody but given their case load they're, they only see gay male patients. One, are we already starting to see that too? Is that what you're talking about when you're seeing that growth in the next decade and a half?
[00:29:31] Dr. Daniel Kaser: It's a really interesting question. And I honestly feel like based on my own clinical volume, I could do that. I almost could do that now. My partners would probably kill me.
[00:29:41] Griffin Jones: But why would your partner stay?
[00:29:43] Dr. Daniel Kaser: Know just based on the clinical volume. But I think frankly at some point I'll probably be there markley and dearest RMA Connecticut is really become a mentor of mine over the years. And he's honestly the only one of the only docs that I know that like exclusively cares for men going, going through the process.
I dunno if I would necessarily like, be that specific in like all egg donation, all surrogacy. I frankly like the whole breadth of doing donor inseminations for single women and lesbian women and frankly being helping members of this community get to the point of being a parent.
So I do think, in particular, I do know some other recent graduates that are gay and are open about, about their life experiences, I think have interest in this as well. And even some current fellows that may as well too. So I genuinely think that this is like, it's a very specific segment.
But I think if done well, you can, you can this can be like a reason people seek out your practice and it's a way to differentiate your
[00:31:00] Griffin Jones: practice, frankly, Dr. LeondiresLee and has been on the show as well. We'll link to that episode. It's probably a two year old episode. Now we'll link to it in the show notes.
Why did you move out to the bay area?
[00:31:12] Dr. Daniel Kaser: I moved to San Francisco to help RMA of Northern California open and kind of establish their third-party program and help develop kind of LGBTQ care here as well. I also am like joined two really great friends as partners and it was another great opportunity at the right time.
[00:31:34] Griffin Jones: So it is RMA of the Bay Areabarrier. Is that also part of Eva RMA or it's different because I know that there, like you mentioned, Mmark LeondiresLandis of RMA of Connecticut who had, who have just rebranded. So their Allume fertility now, like that's not part of VRMA neither, neither is RMA of New York. And then, there was RMA of Texas and they're not an RMAIronman anymore.
And then there's others that are, they're all straight up part of the same VRMAEVR. I'm a company. Nobody seems to know the answer to that. So where do you guys fall in that spectrum?
[00:32:02] Dr. Daniel Kaser: It's a great question. We are a part of the RMA network or UV RMA in northern California.
[00:32:09] Griffin Jones: Okay. So your true blue EVRMAavian army.
So you were staying within the same company. You knew where you were moving from the east coast to the west coast. They were starting, they were building that practice out there and there was the opportunity to, to, to relocate You mentioned there any other major, I mean, New Jersey, hadn't had a mandate.
You mentioned though that their mandate wasn't completely inclusive. , and now you're in the Bbay Area were there other major differences between the two states that are worth mentioning?
[00:32:39] Dr. Daniel Kaser: That's interesting. I would say in California particularly in the Bbay Aarea, there's more directed, like known egg and sperm donation then out east, at least currently, or where in New Jersey, I was in practice in that Individuals and couples come with like a particular person in mind that they're wanting to donate.
And I think it frankly speaks to like how fluid certain kind of families are and like what family looks like, and, and the 21st century in that, I have frankly friends that, other gay men who have acted as a sperm donor for like a single woman, for example. And so in, in California, I see more and more of those kind of creative ways that you can start your family.
And I think it's really rewarding to not only help like screen and educate the sperm or egg donor and what they're doing and, and link them up with, reproductive psychologists and counselors who help them navigate frankly, what this means for their life and what type of relationship they want to have with the child.
But it's I think more and more, at least in this community Important for for patients to know their donor. So I think the trend is probably moving away from kind of anonymous or not known egg donation and sperm donation people, frankly, we talk at every consult when, when using donor gametes that, it's not truly anonymous.
And in particular with, Facebook and 23 and me Google image search, if you wanted to find your donor like an anonymous donor you're absolutely would be able to do so, or like often.
[00:34:31] Griffin Jones: So for that reason, we don't say non miss anymore, but are you saying not just not just for that reason.
Can we not say anonymous? Are you also saying that we're moving away from undisclosed? That it's, are we moving back toward, are we moving towards disclosed for that reason?
[00:34:47] Dr. Daniel Kaser: Yeah. I mean, I see more and more people choosing like the open ID or identity release, where you can like learn about the sperm donor at age 18.
If the child wants to, or doing truly like known or directed sperm or egg donation, just say the child has an option to, to like meet their part of their origin story and couples navigate that differently. The couple or the child or number want to explore that. And others, others are really curious about that when my husband and I went, went through egg donation, we we wanted to like have an egg donor that we knew.
And we did so through the, through the practice and met her, not only really, for two reasons, one was to protect that option for future contact. But secondly was frankly just wanting to thank her for truly like what a life-changing thing that she has done through egg donation and every donor that.
I tell him or her that in that I genuinely thank them for what they're doing for that couple. And I think on a busy day, it's like easy to, to lose that perspective. And it's easy to think about the egg donor who had 30 eggs retrieved and what a great response she had, but in particular, like, going home to a child from an egg donor and like playing ball in the backyard or holding your son reading them a book, like recognizing that, like the only reason that, that you're in that space is through like some altruistic act that, that someone else went through.
I think it gives you like a tremendous amount of perspective and just, you feel so grateful that like what, what these men and women are doing. And so I like caring for the donors themselves too. So it's a part of that is like, educating them not only about their own fertility and like about their hormones and their body but also just, letting them know what an important task that's what an important endeavor that they're undertaking and to thank them.
[00:37:00] Griffin Jones: Well, we've made some creative about that.
And that makes me think of some more and that topic could be, could be its own show topic. I'm going to let you conclude the way you want to conclude about the future of third party, but the feature of serving LGBTQ plus patients. But before I let you conclude, however you want, I'm going to, I want to drag you into a fight, Dan, and you can choose to pick a side in the fight.
You could choose to break up the fight but I am dragging you in here. And this is the fight, which is recently I've had. And everybody's allowed on the show. We've had 130 plus I think you're going to be episode something 130. Plus everybody is allowed on this show, small practices, large practices, people that are coming from venture capital and private equity people that say they're going to stay independent forever.
Everybody's allowed on recently. I've had a couple of groups on one in particular that has a model of expanding or their value prop, whether they serve it or not is another question. But their value prop is to expand care by having RBIS oversee. OB GYN or maybe PA isn't it NPS.
And and so this, this has started some stuff. I think they're going to come back on the show stomach of at least one of the doctors that I had at Christmas has volunteered to come on and, and hash this out. And and I was at PCRs and people were bringing it up to me. And so I wonder where you sit on this and I want to say, I did get emails from REIs as well.
That said, I love this idea. Can I talk to these people? And there are already REIs that are already doing this model on, on their own. But the objection of course, was Dan that, that can, somebody just can just a, a generalist, OB GYN. Who's never sat through any part of fellowship training, do what I do.
And where are they being transferred? Are they being shipped down someplace? How many cases is the REI overseeing, how closely are they overseeing them? Are they doing it remotely? Are they right there in the office? And so that you're board certified REI Indeed and you're someone that sees the bottleneck of care and that only a fraction of the people that need treatment in this country are getting it.
Where do you opine on a solution like this?
[00:39:17] Dr. Daniel Kaser: Yeah, this is I think an important point and I think we'll, we'll, we'll see this settle out sometime in the next five to 10 years, in my opinion. And I completely agree that you, you speak, we talk to different REI's and you'll get different opinions of this. I, my personal take on this is truly I could write. Be the doctor that I am care for the number of patients that I do on a regular basis care for the type of patients that I do without, advanced practitioners like nurse practitioners and, and physician assistants, for example our practice in Northern California is relatively small in terms of physicians.
I'm one of three docs here. And then we have three advanced practitioners. So two NPS and one PA, and the advanced practitioners help with monitoring with ultrasound, with insemination to sailing sonograms with notably donor screening with gestational carrier screening. And they're absolutely superb in what they do and they bring such a additional kind of level of care to patients.
And, I think are a member of the team, like are absolutely critical to our team functioning as it does. So I think they frankly allow me to be a better doctor. And I honestly go to them sometimes asking their opinion of things. If I have a catheter placement for a saline sonogram, that's tricky and my partner is out that day.
Absolutely. I'm gonna ask for, one of the nurse practitioners to come and see if she can, she can pass it. So I have no, no pride there whatsoever. And we've two of the three advanced practitioners that, that are on staff with us right now. We've trained like from the beginning and you can, absolutely have them kind of augment your practice and some of them started.
[00:41:08] Griffin Jones: Did you manage 10 of them or 20 of them remotely. And could you, or if they're OB-GYNs and if they're doing the retrievals and the transfers, are you still on board then?
[00:41:19] Dr. Daniel Kaser: Yeah, it's a great question. Whether like to, what, what point of, of care that, that someone outside of an REI doc would, would be involved?
I personally think like embryo transfers, shift. There's so much an embryo transfer is like the culmination of someone's treatment. And so much goes into that in terms of IVF lab, the costs, the emotions, the physical aspect of IVF. I personally don't think, many patients would, would be on board with having a non position or like, not even there.
Doctor not do the embryo transfer.
[00:41:53] Griffin Jones: So I think that was, they might have, it's a question of age of eight grand all in including meds and everything else versus 20 grand all in name. They might Dan.
[00:42:02] Dr. Daniel Kaser: It, no, I mean, if, particularly if you tie int cost, I mean, you have a compelling point that like maybe they don't care as much as they might expect, but there's always going to be patients that do.
And I think we're at a unique kind of crossroads in the, in the specialty, in that like we're seeing increasing volume. We have like a certain number of trainees 40 plus that, are finished fellowship each year. And as you, in your own words, there's a bottleneck in clinical care.
And so. I see a couple of things happen to in frankly and I see some, some practices going the route that are cost cutting and ways to offer more affordable fertility care and like improve access to care with, in the hope of, driving up numbers and driving up frankly the number of patients that you can help.
And then I see other practices taking a different stance and this is like a kind of a premium product that we're offering. And, people are willing to pay like, Dollar for higher value for better outcomes for more personalized attention. So, I mean, I honestly think there's probably space for both in, in fertility care because not every patient is looking for the same thing.
I think like to pigeonhole, like all fertility patients into wanting like the lower cost option. I think it's, doesn't capture the breadth of patients that we see. I think there's room for kind of both those models.
[00:43:35] Griffin Jones: So, and this should, there should be a debate really, should it not in one of the little breakout rooms either it should be in the big room because I think it would shake up some salt.
You could be the moderator. And I think that it's a good topic and standing room only.
[00:43:53] Dr. Daniel Kaser: Yeah, I agree. I mean, I think it's an important, important thing. And I think if we don't actively like discuss it, I think there is some tension there.
[00:44:02] Griffin Jones: But I don't want, I don't want somebody like you arguing either side, Dan you're too in the middle.
I want people on hard on each side arguing it. And then I want somebody like you to moderate, to moderate it, Switzerland. Okay. You can be, you can be Switzerland. I'm Switzerland on the show, but I have zero clinical knowledge, which is why I always, whenever I bring somebody on, like I say, this is what I'm seeing in the marketplace.
You all decide if it's clinically valid. If it's the best standard of care or even acceptable standard of care, I'm not qualified to give first aid to a paper cut. I was a D student and then I went and got a communications degree from Oswego state, which is why I own a marketing firm.
So I let people talk and then I let the clinicians deciphers out. But I think that would be a great for you to debate. And before I let you conclude, I want to say, if anyone is listening, I would love to do an episode from somebody from a bog to talk about what it would actually, what would actually be involved in going from.
Fellowship programs to a hundred I've kind of asked guests that Al a carte on the show. I would love to talk to somebody from bog who, who could really spend a podcast episode going through what that would be like to go from 40 episodes to a hundred. So if anybody's listening, that's an invitation or a request to the email me, if you can hook that up, Dr. Kaser I'm going to let you conclude with how you want to either about serving LGBTQ plus patients, or just about third-party program in general the audiences, yours what are you paying attention to? What do you want to see for the field? How would you like to conclude?
[00:45:38] Dr. Daniel Kaser: Thanks for having, for having me on the show. I'm a fan and like, it's really an amazing opportunity for me to talk to you about this. I would leave you with, for listeners who, whether you're a physician or a nurse or an embryologist or in marketing at a practice, really any role is just to look inward for a moment in terms of how you're caring for the gay community.
And, I had given a talk at the most recent PCRs this year about quote unquote LGBTQ friendly practice. And how do you build a friendly practice. I had just finished at the, when I was putting together the slide deck I had just finished “How to be An Anti-racist” by Ibram X. Kendi.
The fantastic book that like talks about just structural racism and just how things embedded in the system whether conscious or not can impact people's lives in a material way. And in reading that book, I started in preparing my slides for that talk. I started to think about are we really talking about LGBTQ friendly care?
Is that really what our patients deserve? And I came to the conclusion, ultimately that we should really be doing better than LGBTQ friendly. Well, what my community is looking for and fertility care is to go to like a welcoming practice or practice that celebrates their family story.
And frankly, one that's not homophobic. And so, like the thesis of that presentation was not talking about how to like, run an LGBTQ friendly practice, but rather how to run an anti homophobic practice. And, I think semantics are important. And I think if you haven't read that book, it's absolutely worth the read how to be an anti-racist.
And I think it gave me some of the tools to fight. Like critically about my own practice and ways to improve it and would just encourage listeners to do the same and consider how we can rise to the unique challenge of caring for men and women who want nothing more when they're sitting across from to become a parent.
[00:47:58] Griffin Jones: Well Dr. Dan Kaser thank you for coming on the show. I have another book. Woke Racism which is a rebuttal by John McWhorter, but check out both books. And Dan had the last word. So read Dr. Kaser's book recommendation first Dr. Dan Kaser. Thank you so much for coming on Inside Reproductive Health.
Thanks Griffin.