Everyone says we need more REI Fellows, but how do we get them?
In this episode, Dr. Rachel Weinerman sheds light on what is required to make more REI Fellowships and Fellowship Programs, and why those two solutions aren’t exactly the same. Dr. Weinerman talks about:
Creating REI fellowships: Exploring the steps in establishing robust REI fellowship programs.
REI fellowship funding and operation: What Medicare pays for vs what the institution pays for.
What an REI must do vs what another ‘IVF specialist’ can do
Specific resources that SREI and ASRM can contribute to Fellowship growth
ACGME’s role vs ABOG’s role in accreditation and certification
The limitations and scarcity of Privademic Partnerships
Dr. Rachel Weinerman’s LinkedIn
Company Website: uhhospitals.org
Transcript
Dr. Rachel Weinerman 00:00
So where are we now in 2023, we have comprehensive training programs that train OB GYN who are already fully trained OBGYN to become reproductive endocrinology and infertility physicians. Now, I said reproductive endocrinology and portfolio positions. This is very different than training an IVF physician
Griffin Jones 00:28
Who the heck is going to pay for all this? Today we talk about Rei fellowship programs and Rei fellows answering those two questions because they're not exactly the same question. The question of how you get more Rei fellows isn't necessarily the exact same question as how you create more fellowship programs. But we do talk about both of those questions. My guest is Dr. Rachel Weinerman. Dr. Weinerman did her fellowship at Penn. She's been at university hospitals in the Cleveland area since 2015. She's been their program director for the fellowship program there since 2021. And she's got some ideas. First, I kind of poke at her for a little bit. And I make us spend some time on this question that we've talked about a lot on this show, which is what does an REI need to be doing versus what does the IVF specialist need to be doing? Because very often, we approach that question from the other way, the way we usually approach that question is how much Rei training does an IVF specialist need to have? So I tried to take that question from the other way. And I made us spend some time on it even though it isn't the main topic of this episode, because I wanted to try to isolate how important is the scarcity of REI fellows? If the volume question isn't at play, if technology solves for a big chunk of the volume question is the lack of Rei is still a problem. I wanted to isolate that and I think we did successfully then we started to get into the steps of setting up an REI fellowship starting with the roles what's a Boggs role, what's ACGME his role, we talked about ACGME rules. We talked about Medicare rules, we talked about what Medicare pays for not a lot. And then we talked about what the institution pays for. And that got us in more to the costs of running an REI fellowship program, the irei salary, their insurance, their mail, practice their benefits, paying for program coordinators, paying for other conferences, training capacitation and other professional development. Finally, we talked about who's going to pay for all this and what are some ideas ideas, including allow Rei fellows to perform those services for which they can build up to the capacity for which they're allowed to build national organizations like ASRM and Sri possibly contributing to a fund and things those national organizations can do beyond just funding like standardizing a didactic curriculum suggested rotations and we talk about this trend of private Demick partnerships, but also their limitations. Why have we only seen some of them and not an explosion of everyone doing them? Everyone seems to agree that we don't have enough Rei is coming out of fellowship, regardless of where they stand on how much Rei training they think IVF specialists need. I've never had anyone argue the opposite, that we have too many Rei fellows or that we don't need more if you do have that viewpoint, you're welcome on the show. But this is a problem that everyone seems to have consensus from that I can tell. And so I hope you enjoy Dr. Weinerman's insights on why this is happening and what we can do. Dr. Weinerman, Rachel, welcome to Inside reproductive health. Thank you. It's a pleasure to be here. You were a profile of person that I wanted to get to know that I am glad I've gotten to know this year because I really am interested in how the REI fellowship works, how we get more of them. What's necessary what's not necessary because I'm not a clinician I can't get I don't have a dog in this fight of that we should be training OBGYN to do A and Rei is don't need to be doing B I can't really opine. I can only facilitate the conversation and try to pull in as many points of view as I can. You are a bit more qualified to opine. And so I want to start with just let's start with the importance. What are the important things in your view that REI has learned in fellowship that can only be learned in Rei fellowship?
Dr. Rachel Weinerman 04:05
Yeah, great question. And thank you for having me on the show. I want to start by saying that my opinions that I express are my own. I'm not representing any official organization within the world of Rei. I am program director. So that makes me I hope qualified to discuss this topic, but I'm really sharing my own opinions. So first of all, let's think about what is the history of REI training. So Rei fellowship has existed since the 1970s. When these evolved and adapted, you know, in 1974, when the first board exam was given in Rei IVF didn't exist. So what we've done in training our REI has obviously evolved in the last 40 plus years. So where are we now in 2023. We have comprehensive training programs that train OB GYN who are already fully trained obyns. To become reproductive endocrinology and infertility physicians. Now, I said reproductive endocrinology and fertility positions. This is very different than training an IVF physician. Because what we're trying to accomplish in an REI fellowship is to train subspecialty physicians who are experts in reproduction, who can serve as consultants to general OBGYN and other physicians, and who can provide comprehensive clinical care and infertility and other reproductive disorders, as well as innovate and move the field forward. So that we are constantly improving our knowledge and what we can do for our patients started. That's the overview of how we frame our fellowship training. And I think that really informs what we do in a fellowship.
Griffin Jones 05:48
So how much of a rabbit hole do I want to go down? Now? I guess I will touch it a little bit that where someone who is doing IVF doesn't necessarily need to be in Rei, are you simply making the distinction that Rei is a lot more involved than just IVF?
Dr. Rachel Weinerman 06:03
I would say the latter. I think that currently the way that we structure IVF practice in this country, and we can discuss whether that's going to change the future or not, in order to practice IVF, with the full depth of the field, you have to be trained as an RBI physician, and ri physician doesn't just do IVF. But the knowledge that you get the depth of experience that you get informs your ability to provide proper care in IVF. To put it up maybe a little bit more specifically, the way that I train my fellows. I want them to be able to be creative, and how they provide IVs care, I really don't want them to practice algorithmic medicine. And in order to do that, you have to understand the basic physiology, you have to understand what's happening at a molecular and cellular level, in order to make decisions that best account for the information that you're getting in real time.
Griffin Jones 07:03
Is that at odds with an operational scaling system, I had one guest, a CEO from a fertility network in India that that that episode will almost certainly have aired before this one does. And he was speaking about their network has one set of protocols, there's one protocol per patient profile, and they have 250 physicians. Now there isn't an REI fellowship in India. So these are OBGYN physicians, but they have 250 in their network, and they're all practicing from one set of protocols. And I said, I have worked with two Doctor Rei groups in the US that have different sets of protocols. And so is what you're saying where you don't want your Rei is necessarily practicing algorithmic medicine. Is that odd with a scale of operations of something like having one set of protocols?
Dr. Rachel Weinerman 08:05
That's an excellent question. And I think this gets to one of the biggest questions within medicine is do you practice based on what we call standards or algorithms? Or do you practice based on individualization? And I think that in America, we have excellent outcomes. And IBM, obviously, they couldn't always get better. And what accounts for our excellence? Well, there's many, I would say many things. But I think one of them is our ability to provide high quality of individualized care. Now, that's different, right? In large practices versus smaller practices. And you might say that large practices do have more of a focus on standardization, which is another word for algorithm. But when you have physicians that have that in depth training, they can pin it. So the way that I tell my fellows is, you can do the first cycle as an algorithm. Right, but in that first cycle is successful. Great. But if that first cycle is not successful, what's going to be your next step? How are you going to pivot and change your treatment plan to account for what happened in that cycle? And that that's very difficult to create algorithms that account for each situation that you might encounter.
Griffin Jones 09:14
So that's on the side of, of how much RTI training should IVF specialists be able to have or at least be involved in? How much else should RBIs be doing beyond? IVF? So I'm thinking of the question this wave, when we have David Stabler and a number of others, I will say we're doing about 200 250,000 IVF cycles in the US we need to be doing somewhere around 2 million perhaps more than that. And, and so that is to suggest that we need more IVF being done, but if there are other ways of being able to scale IVF what else should RBIs be doing beyond IVF?
Dr. Rachel Weinerman 09:59
That is Excellent question. I don't think I have all of the answers to the scalability question, because I think that that might entail a significant reimagining of how we provide care. So I think that's an excellent question. I don't think I have a very specific answer to it. Because I think it's a really philosophical debate about how do you provide infertility services and IVF. Specifically, what a reproductive endocrinologist is trained to do, and we were able to do after fellowship is provide comprehensive care. So that means that if a woman comes with irregular periods, with abnormal reproductive hormones, with fibroids with malaria, and abnormalities, all of those can be addressed in a way that allows her to proceed with her reproductive goals. So that is what every doctor of endocrinologist can do. Can that be broken up from IVF? Again, I don't know the answer to that question specifically, but you can't provide full comprehensive infertility care without those additional areas.
Griffin Jones 11:05
What distinguishes our AI train doctors from other physicians in the field of infertility?
Dr. Rachel Weinerman 11:14
Yeah, great question. So I'm going to assume that what you mean by other infertility physicians are OBGYN,
Griffin Jones 11:21
OBGYNs are, yeah, almost almost certainly OB GYN 's or I guess, advanced practice providers working with OB GYN.
Dr. Rachel Weinerman 11:28
Right. So those are two different categories. So advanced practice providers typically have two years of schooling, after college, and then they don't have any formal clinical training after they graduate their program. So a lot of knowledge gained by advanced practice providers is going to be in the clinical setting on the job, what you might think of as an apprenticeship. And they are trained for the clinical work that they'll be doing, but specifically by who they're working with. So that might their practice styles may change. And then the depth of knowledge that they have is obviously different. And OB GYN will have completed four years of medical school and a four year residency in OB GYN and they they have you know, significant more depth of knowledge, their experience in Rei specifically, may be more limited. Most OB GYN residencies require at least a month of REI training, but sometimes it's only a month. So that's, you know, they obviously have that expertise in many areas with an OBGYN, but they may not have that depth of knowledge to be able to practice infertility and a lot of that learning that would require that would be necessary if they were to practice infertility would have to come after training,
Griffin Jones 12:37
I'm thinking there's a few Fertility Center practice owners that I can think of that were sort of grandfathered in prior to fellowship requirements that never had an REI fellowship. And then there are others that I can think of that work in fertility practices they work with and under an REI in many cases in they have for years, but they never had a fellowship. And and so I don't believe that they're board certified because you need you need the fellowship in order to take the boards, right. You can't.
Dr. Rachel Weinerman 13:07
Yeah, so I can go over that in more detail for you. Yeah, this question of okay, you have some Doc's that were grandfathered in. And you have other Doc's that maybe they weren't grandfathered in. They're still working with REIs, but they've been doing it for 15 years. And so what does an REI fellow What does someone gain in Rei fellowship that they might not have gained? Well, first of all, is a great question. We do have doctors who are grandfathered in, I would say many of them are older, you know, pre board certification for i o that that is tend to be phased out. You know, 15 years is a lot of experience. I would say a lot of OB GYN working now may not have that length of experience going into an infertility practice. But let's talk for a minute about what Rei fellows do do and fellowship. Currently, fellowship is three years in the past used to be two years, there's some discussion about whether that link should change. Fellows are they do at least 18 months of clinical rotations, that includes training in infertility and what we call a RT, not just IVF. They do surgery. They do genetics, they do male infertility, endocrinology, pediatric endocrinology, and increasingly spending time in the IVF laboratory learning IVF techniques, then they spend at least 12 months doing research. And that research culminates in a thesis called a scholarly thesis that has to be presented. And it represents a significant scientific effort, which demonstrates knowledge not only of the scientific literature on the scientific method, but how to critically appraise what is happening in the world of scientific knowledge and Rei, and how did you innovate in that field that demonstrated by doing that type of project, and then they typically also have six months of electives, which can be individualized to the fellow and their and their training requirements. So that's The overview of what they do in order to then actually practice within the field of REI, they have to take a an exam from the American Board of Obstetrics and Gynecology, it's actually two, they take a written exam called the qualifying exam. And then they take an oral exam, which is the certifying exam. after they graduate, they collect cases for 12 months, and submit their case list along with their thesis in order to sit for the exam. And then they take the exam, which is a three hour oral exam. So there is a breath that people are learning in the REI fellowship program. And that takes me back to the question of what else should always be doing and I thought of a different way of asking the question. So if we're doing 250,000, IVF cycles or so we should be with 1200 RBIs. And plus probably some others, because that almost certainly includes OBGYN who are part of that process. But let's just say we've got 1200 RBIs in in the country right now doing 250,000 cycles. If with technology with training other Doc's and other positions, massive operational improvements in the next 10 years, we are doing 2 million IVF cycles from 1200, RBIs, or even fewer. What I'm saying is right now a lot of the argument for increasing the number our very eyes is because we need to to meet the demand, let's just pretend that we can meet the demand with with the improvements that happen over the next 10 years. Do we still need more REIs, then if we're if we're seeing if we can meet the IVF demand? Do we still need more areas? And if so, what for? So I would I would answer with a resounding yes. I think we need more. And I think what I'm when I'm describing about Rei fellowship, and the intensity of fellowship and the value of fellowship, doesn't change the fact that we don't have enough REIs. And we can talk a little bit about some of those impediments. Why we don't have as many Ira fellowships as we do, how do we train more Rei fellows. In the end, in order to practice quality medicine, you need more REIs, even if those Rei are supervising they advanced practice providers or other physicians that may not have Rei specialty training, in order to scale up as significantly as you're describing, you would still need more REIs in those roles, they may not be always providing the direct care, like they may be supervising other providers. And I would say that that's an appropriate role. But if you don't have an REI involved in that supervision, then likely the quality of care will not be what we want it to be. And the innovations won't occur.
Griffin Jones 17:41
Is there anything else beyond supervising IV? Is there more research that needs to be done? Is there more? Are there other areas of medicine that era is should start to be? I guess I don't know what the word would be cross discipline with is beyond supervising to meet that scale? What other responsibilities should the REI take on if AI and all of these other technologies and systems do in fact, and I understand it's a big caveat. But Fiat that may for a moment, and what else should they be doing?
Dr. Rachel Weinerman 18:15
So let me put it this way. There's a debate within the world of REI as to how much that II shouldn't be there. Right. Rei is reproductive endocrinology and infertility. How much should the REI focus be on endocrinology. That's historically what the field was, again before IVF existed, you know a large role that that the RBI had was in managing hormones. Now we still do. But that looks different now that we have AR t as a huge component of what we do. So should that E be replaced with for example, a G for genetics, a lot of what we do now is involves very complex genetic information, both from the perspective of the patient and the patient's partner, and from the perspective of the embryo. And the information that we're getting is, is enormous, it's complex, and it's changing. So to be able to adapt to care for patients in this changing environment, that is an area of focus that Rei might consider in the future. The other question is gynecologic surgery. And that historically has been a very important part of what Rei is do and is still a very important need. There are many patients whose fertility needs cannot be solved with AR T alone. They need surgery in order to be able to accomplish a successful pregnancy. And that historically has been the role of Rei. There are now more widely invasive surgeons within the world of GYN who do some of that surgery. That I would say is an open debate. There's many different opinions. I personally work at an institution that is very surgical heavy, and we are able to provide that type of comprehensive care for our patients. So let's say what else could REI be doing? I would say those are two areas that I would say we have to think about how much we want REI involvement. And then I would say what you mentioned about research is extremely important. I use the word innovation before. And I think that, to me, research is a prerequisite for innovation. If you don't have people trained in being able to perform research, and assimilating all of these types of complex data, you will not see innovation in the future, you will not see improvements in pregnancy rates, you will not see improvements in the what we are able to provide, I don't know what IVF is going to look like 40 years from now, I hope it looks very different than what we're doing. Now, I always tell my patients, you know, I have to give them the option of donor egg, for example, now, because they don't have, you know, any egg reserves to be able to get successful autologous IVF, I hope that's different, you know, by the time I retire.
Griffin Jones 20:57
the reason I kept poking at that is because I said, this kind of Nexus where there's a lot of venture capitalists and private equity people, as well as fertility practice owners and doctors. And so and and see them come together, and I see them having conversations, a part of one of the conversations that is coming from the doctor, and is well, what do we do if AI is really able to scale us up to this level? If, if other doctors are able to do these procedures, if we're able to use technology and systems to answer a big chunk of the volume question, then what is it else that we do? And and so where your mind went with that is, is the answer that I've been looking for it to that is because there's going to be something for you all, I try to tell the REIs don't freak out, it's just going to be, it's going to be different, I think you're going to be doing just fine, no matter what happens, but I think it will be very different to 10 or 20 years from now. And I'm neither a clinician nor a futurist. So I have to pull it out of I have to make people like you speculate in order to try to paint a picture, in that you started to talk a little bit about why we don't have enough programs. And I in my view, I'd say we we don't have enough. We recently inside reproductive health wrote an article, the journalist interviewed you. She also pulled up some numbers on the number of programs. And I think the according to the National Resident Matching Program, there were 49 Open fellowship positions in 2022. And I want to say that was like from 41 rei fellowship programs, according to that same that that same national Resident Matching Program, so why isn't enough? Why isn't it enough? Why don't we have more?
Dr. Rachel Weinerman 22:42
Excellent question. I don't think I have all the answers. Do you know why? Why don't we have more, but I can begin to explain from our perspective now. Maybe you know what some of those answers are? I would say that the answer your first question is we do not have enough. And I think that is that is a consensus, I would say among most RBIs we need to be training more fellows to be able to provide high quality, fertility services and our guy services in the future. Why don't we have enough? So let's start with a little bit about how Fellowships are structured, who pays for them? And I think that might answer some of the questions. So first of all, infertility Fellowships are under the rubric of what's called the ACGME, the Accreditation Council for Graduate Medical Education, and a bog, which is the American Board of Obstetrics and Gynecology. So with our long names, but essentially ACGME accredits programs, you know, allows them to function and then fellows are certified by a bar. So those are the two organizations that are in charge. In order to be an ACGME approved fellowship. There are a lot of requirements. In fact, there are I just looked at the program requirements before our session today, there is a 56 page document of everything that a program has to do to have a Rei fellowship. That includes being under the rubric of a sponsoring institution that has an OBGYN residency. So you can't have a fellowship without being embedded in an OB GYN residency, which is essentially most likely either an academic institution or a large institution that can sponsor that. And you need to have a program director who has dedicated time program coordinators who have dedicated time you have to have ancillary services in many other specialties. Medical endocrinology, pediatric endocrinology, genetics, male infertility, full operating room, full hospital privileges, access to the medical literature, I mean, the list goes on. So you can imagine that this is not an easy thing for lots of institutions to do. And it takes about two years to get a fellowship up and running. And then the second question that I I alluded to was, who pays for this? Because it's expensive to run an REI fellowship fellows typically costs somewhere between 100 and $150,000 a year. Some of that money comes from Medicare, actually, Medicare pays through direct and indirect funding to hospitals. But the number of fellows or residents that can be paid for through Medicare is actually capped. And those numbers are capped based on 1997 Trainee levels. So it's very difficult to get funding from Medicare for a new fellowship. And so often, that funding comes from the sponsoring institution, whether it's the hospital or or practice. And it makes it challenging because fellows actually can't bill for their time. So your training fellow, but that fellow is not going to make you money in the short term, because fellows have to be supervised, and you can only really bill for the time spent by the attending physician. So they're not making you money, you're spending money on them. It's an investment, but it's not an investment that everyone can do. So I'd say the combination of the logistics of running a program and getting it off the ground, the requirements, which are significant in terms of what the ACGME asked for in a program, and then how to pay for fellowships are some of the contributing factors.
Griffin Jones 26:12
And when you say it's an investment to train fellow fellows when they can't build for time, it's an investment but very often it's an investment for someone else, isn't it? Right? You are you're the one training them but in many cases, they're gonna go work for someone else, you're gonna go move to whatever part of the country they want it to go to, or people do stay where they went to fellowship sometimes and there is perhaps an increase happening. I don't as we see more of the of the private academic partnerships, but of people staying at least within that organization, maybe I suspect that there is is the limitation in not being able to have more private partnerships that the reason I asked is because when you say that they have to, you know, they have to have an OBGYN residency well, almost every teaching hospital does now I am I you know, I think at the University of Buffalo I think of places like Stony Brook Binghamton and University of Arizona, Arizona state. They all have medical schools and and OBGYN residency. So I believe almost every place that that does, that has a teaching hospital has an OBGYN residency program. Right. So it seems like there's still a whole there's still a whole pool in that group that could qualify. Is it that people that don't have that partnership with an academic institution that can't bring on a fellowship program for that reason? Is that the limitation?
Dr. Rachel Weinerman 27:42
It's one of them. So yes, there are many OB GYN programs out there that do not have attached ROI scholarships. I mean, right. There's only 49 fellowships, there's a lot more OB GYN residency. But if you are a very high volume, private practice, and you you think, hey, I need more Cielos let me open up my own fellowship so that I can train fellows, have them stay on hopefully, in my practice and build my practice that way, you then have to seek out an institution that has an OBGYN residency to partner with, in order to accomplish that,
Griffin Jones 28:15
how much infrastructure is required for that? Because I can think of smaller practices, maybe two to four RBIs that are in the backyards of a lot of these, these hospital systems or medical school, they do have OBGYN residencies, why can't they it seems to just be right now be the larger institution. Can you talk to us a little bit more about what else would go into the infrastructure that would stop a smaller practice group from linking up with a hospital system?
Dr. Rachel Weinerman 28:43
Well, I think that if you have willing partners, you can do it. I don't think that there's a lot of hurdles necessarily to a smaller practice looking at what the bigger hospital system, if there's a willingness on both sides, you know, the hospital then may want their residents to rotate with that practice. And by the way, every OBGYN residency program has to have a relationship with an infertility or Rei division, because it is a requirement of their OB joining residents to rotate on Rei. So I'd say most OBGYN residency programs do have a relationship in some form, with an REI program, you know, either whether it be IVF or an academic Rei division. So I don't know that that's necessarily the hurdle. I think the hurdle is that it takes time to to train fellows, it takes time to set up the fellowship, it takes time to run the fellowship. And there's not a lot of financial incentive for that practice to to pay for that fellowship, unless they know that they are going to be successful in recruiting and retaining their fellows. And in the past, you know, that was actually I would say a negative right people didn't want to retain fellows there was not a not enough spots. They didn't want to train their competition. Now obviously, we're in a slightly different, significantly different situation. So maybe we just need to catch up to that. But I think that the amount of time and the amount of money invested is an impediment to small practices, who may not be able to devote those resources.
Griffin Jones 30:10
Do you think I'm making you think on the spot because I'm just hatching this idea in my brain right now. But the debate that goes back and forth about how much OB GYN should be allowed to do versus how much RBI should be able to do if you were allowed to bill for fellows because OBGYN 's were allowed to do, and there's certain parts of the procedure or they were allowed to bill at the same rate, or I'm, that's beyond my paygrade of the knowledge that I have in that area. But if that were, if it were the case that OB GYN 's were able to build more at what our eyes are able to maybe they are already, but if that were the case, would that then allow for fellowship programs to bill for Rei fellows, has that ever been discussed? And might not thinking of something else? Is there something unethical in there that I'm missing?
Dr. Rachel Weinerman 31:06
So great question. And no, it is not unreasonable to think about, in fact, one of the challenges that we have now within REI fellowships is we have to think creatively about how to get more fellows thoughts out the most fellowships in the country probably have the capacity to train more fellows, and they're currently training. So I know that's true. In my fellowship, I trained one fellows a year, I could easily train two fellows a year, you know, double the number of fellows that I'm training, I could probably even train more than that, you know, based on the volume that we do in both Rei work IVF work and surgery. The main reason I can't Well, there's two, one, you have to get approval from the ACGME. But assuming that you can do that, it's the it's the funding, how do you pay for those extra fellows? So that's something that we are, everyone I think is thinking about that now I'm thinking about it, there is one slight impediment to what you're discussing, which is the regulations that govern what an ACGME approved fellow can do. So within an OB GYN fellowship, like REI, cellos, can bill independently for four hours a week and their primary specialty. So a fellow could do GYN clinic, pap smears, you know, irregular bleeding, anything that is restricted or not part of REI training, they can do for four hours a week. And so there, I think that is an idea is to have fellows Bill independently during that time, and then not be enough actually to pay at least part of a salary salary for all of our fellow sellers. So I would say that yes, that is a that is a good idea. There are some limitations to it. But if done well, in a way that is respectful of what the fellow is there to do, which is to be trained, that that might be a way to allow more fellowships to have additional fellows or to allow new fellowships to start
Griffin Jones 32:54
that up to four weeks in the specialty that they are already board certified in, that they're allowed to bill for? Is that too much of a distraction to their current fellowship? Would that take them away from what they're supposed to be training for in the first place?
Dr. Rachel Weinerman 33:10
Right, so So four hours per week, just to be just to be clear on that. It's what the ACGME specifies. Now, I mean, that's, I guess, a philosophical question. Personally, I think that if, if you're allowing more OB GYN to train as Rei Sallows, I think that half a day a week is reasonable. So I think it probably would not detract significantly from the fellowship, and I think it would allow more fellows to be trained. So I think that's, that is an idea that, you know, I'm thinking about incorporating into my own fellowship.
Griffin Jones 33:40
So it's ACGME that makes the ruling that fellows are not able to bill for the subspecialty that they're training for is that
Dr. Rachel Weinerman 33:50
it's actually it's it's Medicare rules. So because Medicare is paying for, for resident and fellows, we called trainees then they can set guidelines in terms of what fellows can and residents can build.
Griffin Jones 34:04
And this is true for all fellowships as gufram I found this is true for fellowships outside of OBGYN is
Dr. Rachel Weinerman 34:10
correct. This is true for all residents and fellows in the country that are under the auspices of ACGME. Now, what ACGME specifies for Rei specifically, is how many hours an REI fellow can work in OB GYN, what they call their primary specialty.
Griffin Jones 34:26
So I've never actually compared the lack of fellowships and our view to that of other fields is every subspecialty or almost every subspecialty having an issue where they feel that they're not able to produce enough fellowship programs or trained enough fellows per fellowship program or as this how unique is this to REI?
Dr. Rachel Weinerman 34:48
I think it is somewhat unique to REI, and there are you know, most other specialties outside of OB GYN have larger fellowships, you know they might train five fellows a year eight bells a year are fellowships were set up in the beginning, almost more like apprenticeships and so having one fallow became the norm. You know, for each program, it was not necessarily the case for other fellowships outside of OB GYN within OB GYN. It is it is more similar in the sense that most OB GYN fellowships don't have more than one or two, maybe three per year at most institutions. But the number of MSN fellowships, GYN oncology fellowships, female pelvic medicine, fellowships, have all increased much more significantly than the number of REI fellowships.
Griffin Jones 35:35
The reason I asked is because perhaps if this was more endemic to all fellowships, then there would be more likelihood of perhaps Medicare adapting rules set, maybe you could bill partially for whatever it might be, but it's less likely to see any type of change from Medicare, if it's just the field of REI, or only a handful of fields that are having this challenge. So can you talk to us a little bit about the specific costs and probably by the time this episode airs, we we will have aired a or we will have ran another article where the same journalist did it follow up follow up to the to the first article talking about setting up Rei fellowship programs. And it was very difficult for the journalists to to button down some costs. And we had some quotes from your colleagues to talk about a little bit of what goes in to the variables of those costs. But try to walk us through that as best you can. Variables be damned.
Dr. Rachel Weinerman 36:33
Right. So I would say first of all fellows, you know, they don't make a huge salary, you know, especially given the level of training, what they could be making, if they were, you know, at working in independent practice after they graduate from an OBGYN residency program. But typical fellows salaries, probably somewhere around $75,000 a year. So that's a direct costs, then you have the cost of benefits, you know, health insurance malpractice, which is paid for by the institution, you have costs associated with the program, for example, you know, paying for the program directors time and the program coordinators time, there are resources that you need in order to have that program such as access to the medical literature. So if you're in a big institution, academic institution, which you know, a lot of programs are, then that's not necessarily a problem. But if you're in a smaller institution, that might be at an additional costs. And then you have the cost of a fellow education. So you, you know, you are paying for fellows to go to conferences, you may be paying for your fellows to get a master's degree in clinical research or translational research or public health that you know, includes tuition. And then you are also paying for additional educational resources for your fellow. So obviously, that's how the costs can add up to, you know, over $100,000.
Griffin Jones 37:50
And so, in, in your view, what do we need to do in order to be it are the things that can be done right now to get more fellowships? Online? Does it all lie with the institution having to figure out a way to pay for it? Are there other things that we can do right now to get more fellowships online?
Dr. Rachel Weinerman 38:13
Yeah, great question. So I would say, again, this is my personal opinion, but I think that in order to get more fellows, right, which is different than more fellowships, I think that we need to think creatively about how to pay for fellowship. And I think that one of the, we talked about one of the ideas, you know, having sponsorships by you know, national infertility organizations or private organizations, to fund individual fellows or individual fellowships would also be, you know, a great way to immediately get more fellows how to get more fellowships, is to lower the hurdle for entry. Now, that has to be done in a very conscientious way. Because if you're lowering the hurdle, you know, significantly, everything that we talked about, for why Rei fellows are trained in a way that is unique and important for the field are not going to exist. So you have to lower the hurdle in a way that maintains the quality of the education. And that can be done by you know, for example, saying that we are going to provide resources for program directors to you know, maybe have a way of submitting their application without spending hours of their time reinventing the wheel. It might need, you know, lowering the the administrative burden, which the ACGME is already already working on. It could also mean providing standardized resources from national organizations that can be almost like a toolkit. Here's how you start an REI fellowship. Here's a didactic curriculum. You know, here are some common rotation goals. So that way someone can say, okay, great. I want to start an IRA fellowship. Here's how I do it. I think that that's a big challenge right now. And I think that making a more systematized way that we can provide support for organizations to start a fellowship, in addition to financial resources, I think would be very important. And we could do that soon. We could do that and probably increase the number of fellows immediately fellowship, like I said, takes about two years once you apply in order to actually see that come to life,
Griffin Jones 40:18
when you mention national organizations, are you referring to the ASRM? SREI, Who who are you referring to?
Dr. Rachel Weinerman 40:26
I would say those are, those are prime examples of who could provide that oversight. SREI is a national organization that provides oversight for the fellows. So I think SREI is a great organization that can help with some of these proposals that I'm suggesting, which are more, you know, a more standardized approach to starting a fellowship or the resources to run the fellowship.
Griffin Jones 40:47
And so when you say, so if they were to include if they were to help pay for some of these resources and pay for more fellows to come in? Many of those organizations get some of their funding from sponsors. Is there any kind of legal framework that you're aware of that would prohibit let's say, ASRM starting a larger fund for to contribute to more fellowship programs, if it was funded by pharmaceutical companies or genetic testing companies or, or others? Is there anything that prohibits that?
Dr. Rachel Weinerman 41:21
Not to my knowledge, but I'm not an expert in that area? So I would probably defer to somebody from a theorem or Sri to answer that question.
Griffin Jones 41:28
I'll save that question for next time. I have Dr. Robbins on the show as the first first question he's getting ambushed with next time. So and when you talk about having more fellows per fellowship program, you said you could easily do two a year perhaps even more than that. You said that ACGME first needs to approve that how how hard is that is the only reason why people aren't doing more of that right now, because of the cost or are there other hurdles that AC ACGME puts forth? Other than cost to say, No, you can only have one fellow per year?
Dr. Rachel Weinerman 42:07
Yeah, I would say both, I would say probably the main impediment is, but there are significant challenges to trying to increase the we call the complement of fellows. The ACGME wants you to demonstrate that you have sufficient clinical resources and research infrastructure to train that additional fellow men, sometimes they can be picky. So you may think that you have the capacity to train additional fellows, the ACGME might not agree. So I think that is that is a challenge for some fellowships. You know, that's something that we could advocate for, you know, within the field of REI, but I would say that that that probably the answer is both.
Griffin Jones 42:41
Well, you've walked us through quite a bit about how fellowship program gets off the ground, what we could do to get more Rei fellows and more Rei fellowship programs, viewing them as part of the same problem, but two different questions. How would you like to conclude on this issue?
Dr. Rachel Weinerman 43:00
I would say that you're asking an excellent question at a very relevant, I think we are at a crossroads in the field of our AI, we know that the demand for what we will be doing is going to be increasing exponentially. We know that there are challenges that come with that type of growth. And we know that there are going to be many different changes both in terms of technology and in terms of who provides care. I think at the heart, being an REI physician means that you have significant understanding of the reproductive system, and are able to implement changes in innovation and how they provide infertility services. I don't think the role of the REI is ever going to go away. I think that we just need to work very creatively to expand the number of fellows that we're training without sacrificing that level of training, and incorporate Rei trained physicians into a larger team in order to provide excellent care for our patients and hopefully adapt to the needs of the future.
Griffin Jones 44:02
Dr. Rachel winderman REI Fellowship Program Director at University Hospitals, thank you very much for coming on inside reproductive health.
Dr. Rachel Weinerman 44:09
Thank you so much. It's been a pleasure being here.
Sponsor 44:12
You've been listening to the inside reproductive health podcast with Griffin Jones. If you are 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 fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health