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Exploring all the different approaches to IVF.
That’s the objective of this week’s guest, 2nd year REI Fellow Dr. Sarah Cromack, who shares her thoughts on Fellowship, practice preferences and the future of the fertility field.
Tune in as Dr. Cromack shares:
Her 2 objectives for REI Fellowship (that every REI should have)
The criteria for choosing an REI practice (when navigating the interview process)
Why she prefers a bigger practice over a smaller one
Where she stands on the Fellowship length debate (3 years or 2)
What she’d like the fertility field to look like in 20 years
Dr. Sarah Cromack
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Transcript
[00:00:00] Dr. Sarah Cromack: I think any group that has five or more docs you could consider as big because it means you're not going in every weekend or like you're not going in less than one week a month. So if you're, a four doc practice, you've definitely, if you're doing IVF on the weekends or you're probably on call one weekend a month. But bigger than that, so five or more, you may not have to go in at all during the month.
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Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser.
[00:01:15] Griffin Jones: Every possible way to see how IVF is done. That's a noble objective for an REI fellowship, isn't it? In this episode, I interview an REI fellow that's halfway through her fellowship. Her name is Dr. Sarah Cromack. She's second year at Northwestern. She did her residency at UT Southwestern, medical school back home at Emory in Atlanta, and now she's thinking about what the future of the field looks like and what her future career looks like.
Dr. Cromack shares the two objectives that she had for her REI fellowship that maybe every REI should have. She talks about five of her criteria for choosing an REI practice. She's interviewing now what's important to her. Why does she prefer a bigger practice over a smaller practice? How do her interests align with the privademic model?
She didn't use those words, but it was something that I inferred. I'm curious if you infer the same. Where does she stand on the fellowship length debate? Three years versus two. And what does she want the field to look like in the next 20 years? If you're recruiting fertility doctors right now, I invite you to be a bug on the wall in this conversation and get to know what people in Dr.
Cromack's position are looking for as they interview for jobs. Enjoy this conversation with Dr. Sarah Cromack. Dr. Cromack, Sarah, welcome to the Inside Reproductive Health podcast. Thanks so much, Griffin. Happy to be here. I didn't even ask you in our prep, is Cromack how I pronounce your last name?
[00:02:28] Dr. Sarah Cromack: It is.
Yes, I did just change my name from a much more complex Capelouto, which was my name before I got married. But Cromack was
[00:02:35] Griffin Jones: How do you practice? Do you practice Dr. Cromack or as Dr. Capilouto?
[00:02:39] Dr. Sarah Cromack: I changed my name and went for Dr. Cromack. It was a bold move to change in the middle of fellowship, but I went for it.
[00:02:45] Griffin Jones: Welcome onto the program. I look forward to talking to you about what you want to get out of your fellowship, your second year fellow at Northwestern. And so I want to start broadly, it's, it has surprised me how popular some of the fellows episodes have been, not just with fellows and aspiring fellows, but some of the Docs that are closer to retirement or maybe halfway through their career.
Sometimes it's because they want to grumble at what the fellows think is an ideal picture of what they're going to do with their career. And sometimes I think they're just curious to be bugs on the wall. I try not to let the fellows be too Bushy eyed without, sharing some of their own experience and what they want.
So every one of these interviews is an end of one, a focus group of one. But this I do think it's interesting just to see what people are paying attention to. And you were connected to me through our Mutual friend and your colleague, Dr. E. Feinberg, and she had a lot of good things to say about you.
So you're doing something right in in, in the very beginning of your career. And I'm interested in what you're paying attention to. So what are you trying to get out of your fellowship?
[00:03:54] Dr. Sarah Cromack: Yeah, absolutely. I was, so I'm definitely providing the young millennial perspective of this. If anyone wants to listen, that's not a millennial, I guess that's a.
You know what you might get out of it, I would say right now in terms of what i'm getting out Of a fellowship i'm super lucky to be in a fellowship that has a lot of attendings We have 12 faculty right now, so one of the biggest things I'm doing is just trying to figure out like every different way you might possibly do IVS and go and see a patient.
So that's the nice thing about being in a fellowship where you have lots of different opinions is you can see so many different ways to do something. So that's one thing is I'm just trying to be like as absolutely well versed and know that when I exit fellowship, I will have seen everything out there and all the different ways to handle it.
I think another thing I'm trying to get out of fellowship is really trying to discover what my niche is. REI is a very, it's a small field. It's a small subset of what a general OBGYN does, but it has so many different aspects to it. It's actually almost crazy. You could focus on uncle fertility, you could focus on third party reproduction, you could focus on recurrent pregnancy loss.
And so I think that's one of the nice things about my fellowship is seeing what act really interests me and what can I say, Oh, I think that's going to be my niche in the future. And those patients that I actively seek out and try and make as part of my population.
[00:05:13] Griffin Jones: So when you say you want to see every possible way of doing IVF, what does that mean with PGTA, without, with ICSI, without, tell me what does that mean every possible way to do IVF?
[00:05:25] Dr. Sarah Cromack: Absolutely. There are so many different protocols you can use, not just that, but how you actually follow someone throughout the stimulation cycle, how you increase their gonadotropins, whether you start with high dose, whether you start with low dose, what level do you trigger at? Do you trigger when they have two follicles over 18?
Are you someone that pushes further? You're looking for follicles 19, 20 millimeters. Are you always doing a mini STEM? Are you always doing antagonists? So we have so many different doctors and we all, they make decisions for each other. So because of how big the practice is, not everybody is making that decision every single time on their patient.
Although we all are, they're always following their own patients. But you'll see how different docs might do a different thing in IVF, and yeah, who's more likely to do ICSI all the time, who's almost always going to have their patients do genetic testing, or who's going to really convince people to not do genetic testing.
And so it's crazy to me that there's just so many different ways that you could do it. And really, it's just all about making sure you're on the same page with your patient.
[00:06:25] Griffin Jones: So how do you know what you don't know in terms of the different ways that you can do it? To your point, there might be a certain number of protocols out there, but there's all different types of ways of doing patient intake.
There's different ways that, people might structure their, the lead up to IVF differently and what they do in the case of a failed cycle or what they do subsequently. So there's all these different ways. And how many docs are at Northwestern? We have 12. You have 12. Okay. So that's a ton. So you might be able to cover your bases with 12 docs, but they are in one place and there's, an infinite ways of doing things potentially.
How do you know what you don't know? How do you get experience if what you really want is to see every possible way of doing IBF beyond just what's available in your program?
[00:07:12] Dr. Sarah Cromack: Absolutely. I think there's really two ways you can do it. There, there are so many REIs and IVF docs that are now on social media and a lot of them are using it as like an education platform.
So I know there's a doc at a Wash U that has these awesome whiteboard videos where he is. showing you the different protocols, what he typically does, walking you through someone's stimulation cycle. And so you can look out there and see what other people like on social media are professing as the thing they do for their patients.
And you can also, go to conferences, stay on top of research. I, I monthly, I make sure I get that FNS email that sends me like, what is the latest update? It's always nice. You can look and say, oh, this group from. Like California, this is what they have been studying and looking at for IVF or SVT protocols.
So staying on top of research it's nice. And I like getting those push notifications either through email or on Twitter too, following SNS, and you can really see what's out there and what people are doing.
[00:08:07] Griffin Jones: This conversation will probably come out in spring or winter of 24. You and I are recording the conversation in December of 2023 which puts you about a year and a half into your fellowship, right?
You're about halfway through. Yep So you got it. What have you? Have you started to form like really strong opinions on certain things? Because I'm not a clinician at all. I I am not qualified to read the scientific literature. I just observe human beings and I see different docs who I presume are each very qualified to read the scientific literature, sometimes have very different opinions.
You have very different opinions on how prevalency should be used. You have differing opinions on the significance of aneuploidy and the use of PGTA. And I hear people debate this and say, okay, you're, you've both read a lot and you've both argued this for quite a bit for years. And it seems to me like it, at some point people I feel like they're convinced by a certain body of evidence, and then it's really hard to, then they would need a lot more evidence on the other side to make them think differently.
Have you started to find yourself in a couple of areas where it's now I feel strongly about X and I didn't coming into fellowship?
[00:09:26] Dr. Sarah Cromack: I will say I feel like I'm still pretty open about most things. You're totally right. People will debate things until the end of time, especially in a lot of REI topics.
That's why they have that like fertile battle in the fertility and sterility journal, because it's just showing there are so many things that are good ground for discussion. I think so many people get really entrenched in ideas about, like you said, whether or not you're going to do ICSI all the time, whether or not you're going to always do genetic testing.
I think I'm super lucky to practice in a state like Illinois, where there's an insurance mandate. So we don't always have to include monetary considerations into treatment. Right now, thankfully, I'm very open. I really think just to doing what is best for the patient, giving them my opinion on the matter and letting them decide, thankfully without a monetary constraint for the most part here.
But I would say I've read enough literature to support both sides on most of these topics that I have not decided what my final opinion will be. And I'm okay with that. I think it's nice to be able to see both sides and offer patients either, as long as they're both reasonable.
[00:10:29] Griffin Jones: How about protocols?
Are there certain protocols that you are starting to find yourself feeling very strongly about?
[00:10:35] Dr. Sarah Cromack: Yeah, I think most of the people in the world of REI these days are probably going to be most strong about the antagonist protocol because it's easy for patients, and again I'm lucky in this, in the state of Illinois that Thankfully, things like Generelx and Cetratide are covered by insurance because they're not cheap.
But, there's interesting things out there. People starting to use things like Provera, which are really cheap to block ovulation. And so I think as we go along further in this road and we discover more and more medications, hopefully, We can drive down the costs. Right now I really think about most protocols from, what is the easiest for the patient standpoint, because what we're asking them to do in IVF is really hard.
And I get a lot of pager phone calls about difficulties drying up and injecting medicine, so I'm always super cognizant of that.
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[00:13:38] Griffin Jones: I'm curious to see if Many REI fellows are malleable enough to work in a system like the one I'm about to describe.
So I don't know if it was like a year or so ago, I interviewed the CEO, Dr. Murdia of Indira IVF. It's one of the largest fertility clinic networks in India, and they have 250 at the time they had 250 fertility docs. Now that. The definition of that word is a little bit different there because they don't have three year R. E. I. fellows. It's someone that is a fertility specialist in India, simply someone that went through OBGYN training and then now focuses in fertility. So the difference in the word is important, but they've got 250 some docs in their network, and they all practice one set of protocols. So in this situation, if it's In this situation, you do this protocol in this situation.
You do this protocol. And I said, I've worked with fertility clinics that have two docs and they practiced different sets of protocol. How do you get 250 docs to do that? And he said, I only hire docs that are younger than I am. And that's how this is the way we're doing it. And we make changes, but only at the systemic level.
We'll make changes to the protocol once we see stronger evidence or All Or maybe new therapies being introduced, but only at the global level when you know, the Advisory board has voted on that but we don't let people do this protocol here and that protocol there. Do you think that I'm asking you to take a straw poll and just put your finger to the wind and guess But do you think that your colleagues your fellow colleagues that you know would go along with something like that?
[00:15:20] Dr. Sarah Cromack: I would guess that about 90 percent of them would not be cool with that if I, I had, I think this is the individualism of the doc here and making our own decisions is probably something very important to all of us that has been, training now for this extra three years and four years of residency and all of the time before that.
So I think we really do have a culture where we're probably. going to want to do different things for everybody. And I think too, we really are taking the patient's opinions into account. And a lot of times people will come to this and they said, I failed this protocol at XX at YZ clinic.
And now I want to try this protocol. And if it's not unreasonable, I think it's fine to do that. And so I think it is certainly their benefits to have a very system, like a systemized. Way of doing things and you can decrease medical errors like that, but it's nice to be able to play with things and give people different options for success, even though sometimes we know that doing the different protocols, you get the same result.
[00:16:16] Griffin Jones: Tell me about why that individualization is so important to you as a fertility specialist and before the audience thinks that answer is obvious from a business. Person's perspective. It's not entirely obvious because we have a massive pool of demand for fertility services. We have a limited supply.
We have a real big problem with the number of people that can get treatment that can't afford treatment. And one of the things that by definition scaling means is doing things the same or similar way. And so tell me why that individualization is so important to you as a specialist.
[00:16:57] Dr. Sarah Cromack: Yeah, no, I totally understand there's like obviously a dire need for more REI doctors and people practicing in this country and if we can Protocolize it to make it easier So that people that are not necessarily REI docs, but are OBGYNs or other can apply these protocols to basic patients, then we can really improve access.
The problem with that then becomes that what is the importance of the REI specialty and why are we doing all this training for three years to learn these different nuances? And there are. So many different patient situations you're going to see and each one of them really can require something a little different.
And I think some people really want you to tell them what you think the best protocol is. Other people want it to be more of a shared decision making based on things they tried before. Other people might just want to change because they didn't get a great result with the last protocol and they want something new.
And so I think, especially also when you would consider sometimes the cost of somebody's treatments and how much people are paying out of pocket, it is really important to be able to take the patient's perspective. into what you're doing. And so I think being able to individualize and provide something that is more really for that patient and that you've discussed with them, makes people feel like they're not like, Oh, just another number in this giant factory of IVF that we're doing.
[00:18:14] Griffin Jones: Maybe that intersects with the concept of niche that you talked about earlier in the conversation. One of the things that you want to do in your fellowship is figure out what niche you're most interested in. What have you clung to so far?
[00:18:27] Dr. Sarah Cromack: Absolutely. So I think right now what I'm really interested in is oncofertility being at a huge program like Northwestern.
We have a fertility preservation navigator nursing team who is amazing and gets referrals from our community. Absolutely. Children's Hospital, from our adult hospital, from other hospitals in the region of patients that are really quite sick. So we get, patients with sickle cell, patients with leukemia, patients with any number of cancers that really need to do IZS rapidly to be able to preserve a chance of having a child with their own eggs.
And a lot of times these people are so sick you have to take them to the operating room to do a retrieval. You have to sometimes admit them after if they have a complication related to their underlying disease. But we have been able to, thankfully, with all this coordination, bring these patients through safely and give them this like amazing opportunity to possibly have a child when they, finish their treatment or get a stem cell transplant in the case of things like sickle cell or anemias.
And so I think that's something that is really bolstering the importance of being able to really specialize and take your time to understand what, what happens with REI in a fellowship because this is not something that you could do just by learning it quickly. It's something you have to see over and over again and really feel like you've got, you're highly trained to get these patients through when they're otherwise quite sick.
[00:19:46] Griffin Jones: These two objectives that you laid out, finding your niche and then seeing every possible way of doing IVF. Do you feel like both of these objectives were laid out for you in well established tracks? Or did you have to do some veering off of an established track in order to be able to achieve those objectives?
[00:20:05] Dr. Sarah Cromack: Absolutely. So definitely the seeing every different way to do It was right in front of me with the ability of having so many different IVF docs and we're on every third week on call. And so we get to make decisions, run through different IVF protocols with all of our different docs because they rotate call.
So that one was, that one's easy. You can, we really are able to learn on the job, which is awesome. Finding a niche, I would say is something a little bit more. Went out and searched for it based on what a lot of my attendings were doing and following and shadowing in their clinics, see what I thought was the most interesting.
And so that when you certainly have to parcel out what you think is the most interesting and hopefully get a good mentorship from that, which I've definitely been able to do in my fellowship.
[00:20:44] Griffin Jones: Is there any other type of track or any other type of objective that you feel you, you don't really see fellowships necessarily offering that the fellow has to take up upon themselves?
[00:20:55] Dr. Sarah Cromack: Absolutely. Good question. I think obviously the world of REI is changing with all of these larger corporations taking over sometimes smaller clinics. We're getting huge venture capital or private equity firms that are now involved. And so one thing I think I have to explore myself is just what the world looks like after fellowship in terms of the business of REI.
Certainly we learn a lot of the clinical aspects caring for patients, but we may not learn as much. Like how to run a practice, how to, work along with colleagues in these different business models, whether your private practice solo or going out and joining a bigger conglomerate.
And so I think, certainly it is something where you have to explore it yourself to see. What the different models are out there. Cause that's not something you might learn in these kind of academic programs that most of us are in.
[00:21:44] Griffin Jones: What does the world look like for you after REI fellowship? Are you still on the dance floor or have you signed with someone yet?
[00:21:52] Dr. Sarah Cromack: No, yeah, I'm still looking for a job right now. So I'm in the midst of my job search, but certainly that job search has gotten earlier and earlier, which is something interesting. And actually, we're doing a research study on that right now to see the trend of. REI fellows in the last 10 years, what kind of groups are they joining?
Are they going more academic? Are we seeing more people go into these larger private practice, mega groups? And so I'm still searching out there. We'll hopefully, I'll find a place close to my family, but. It's interesting, the job market, and I think maybe people are getting into it really early without realizing all the different things that are out there.
[00:22:29] Griffin Jones: How are you prioritizing your job search? What's in your criteria?
[00:22:33] Dr. Sarah Cromack: Great question. I think when you exit fellowship, it's the first time in your life where you say, Oh, this is maybe the place where I'm not going to move for a while. You jump from college to med school to residency.
And I'm from the South, I'm from Atlanta originally. I was there for med school, but I was in Nashville for college, I was in Dallas for residency, now I'm up in Chicago. So it's really the first time where the power is in your hands. And so that's strange. So I think there are lots of different priorities.
For me, one of them, I would love to be back closer to my family, which is in the South. Which is something that it's nice to be able to finally prioritize that. Sometimes you don't have that luxury and the match system with residency and fellowship. You can certainly hope and do your best, but now you can really put your own priorities there.
So I think that's important to me, but then of course, other things are going to be, the culture of the practice that I'm joining, I'd love to join a bigger group practice. I think you have to decide. Do you want to be in a place with a lot of MDs with fewer MDs? Do you want to be in a place that's, physician run that possibly has a venture capital or private equity backing?
Do you want to be in a place where you're interacting with residents and fellows? That's my hope. And so there's so many different things that are involved in this job search. And I think we're also seeing less and less people stay in that one job their whole life. Like my parents are both physicians and they've had the same career as physicians for the last 25 years.
So I think we are starting to see a little bit more of people bounce around from job to job.
[00:24:01] Griffin Jones: Yeah, that's been true in the workforce at large for probably 30 or 40 years, but it was probably less so in the medical profession during that time period. It was still probably the case, and especially among providers that folks Stuck around for four at their hospital or their practice for a while, especially if it was their practice, but now we're seeing, we see partners leave, we see partners get bought out and then start up something new.
We see people go be associates someplace and then not get on a partnership track there and then go get on partnership track elsewhere, be employed elsewhere. So I hadn't thought about that trend before, but I think it's. Generally expected here. Now, at least, hopefully not like the rest of the job market where you see a lot of resumes.
It's eight months here, three months here. We can't have that for providers. But if you go a couple different places over the course of your career, I think we're all okay with that. You mentioned that you're well, let's you mentioned a couple different criteria. The first time the power is in your hands to choose the geo and I never really, before being married to a physician and going through this process and then becoming friends with so many of your colleagues, I never had really considered this part of the reason why I started my company 12 years ago is because I was like, I want to live wherever I want.
And that is just simply not the case if you're a physician in training. Yeah. And so now for the first time. You have this. And so do you mind if I ask where your family is from? What general area your family's from?
[00:25:36] Dr. Sarah Cromack: Yeah. Yeah. I'm, my family's right now is in Atlanta and my husband's family's in San Antonio and Texas.
So mostly for the South, this is the most north I've ever lived, but you know what? I actually like it. It's quite cold, but I have a nice jacket.
[00:25:48] Griffin Jones: Chicago is an amazing city. If it had the weather of a further South city, it would be a pop. It would have a population of 40 million people.
It would be the largest city in the world. The winter is the only thing keeping things under wraps there. But so the reason I ask is because Atlanta is a pretty large city and it's a very large city. It's probably top 10 metro and it has a good number of fertility docs. I don't know if they're if yeah.
Yeah, relative to population. But would you ever consider a small market or it's probably just going to be Atlanta or Texas?
[00:26:19] Dr. Sarah Cromack: It's a great question. I think there's definitely benefits to being in a small market, for example, like you could go outside the city of Atlanta. You could go to Chattanooga.
Or you could go to Birmingham, much smaller markets, and that's nice because you do have a little bit more control and you have less competition in your surrounding area. So you may be that REI doc for, you or five other people might be the only REI docs in the area. So I think there, I definitely would consider like possibly smaller markets, but I do think, in, in medicine in general, so many people are closer to the big city just because that is, the urban space where a lot of us want to live.
But there is definitely a dearth of REI providers. For example, in Georgia, I can't imagine there's many outside of Atlanta or Augusta. There's a lot of other cities there. So we, I think it's nice that as we get big groups like, the U. S. Fertilities and Boston IVFs, we're able to expand and make satellites to reach those people in those more rural areas or, not even rural, just not the main city.
[00:27:17] Griffin Jones: So you're open to a smaller market.
[00:27:19] Dr. Sarah Cromack: Definitely. I think so. I think it's real. I don't think I'd want to be the only REI doc somewhere. And I think it's hard. I think we are losing. I don't think there's a lot of solo REI practitioners anymore as we see kind of these changes in the market. But there is something nice about being, that person in that area.
[00:27:35] Griffin Jones: Be like a Delta flight back to Atlanta or whoever flies to whoever San Antonio's. Yeah. Just something like that, just close enough. Close enough.
[00:27:43] Dr. Sarah Cromack: I'm always, I love getting in my car. I know it's not normal for people. People in Chicago don't really have cars. But I like to drive
[00:27:50] Griffin Jones: small markets on the table that brings us to practice size because you said you'd prefer to go to a big group practice and as you mentioned that there are far less single dot groups than there used to be at least as a percentage of the total number of practices. What do you like about first? How do you define big group? How many docs is that? And what draws you to it?
[00:28:13] Dr. Sarah Cromack: Yeah, I think there's certainly not like an actual definition, but I think any group that has five or more docs you could consider as big because it means you're not going in every weekend or like you're not going in less than one week a month.
So if you're, for doc practice, you definitely, if you're doing IVF on the weekends or you're probably on call one weekend a month, But bigger than that, so five or more, you may not have to go in at all during the month. And so certainly that's the, one of the nice things about that is.
As residents and fellows, we're used to working every weekend, every other weekend, maybe every third weekend in fellowship, but going to a place where it's like, Hey, I actually can have weekends off like my husband has for the last seven years. That sounds nice. And you do get to share a little bit more of those responsibilities.
So when you have a bigger group practice, if you're not able to do something, you're out of town, you do have that capability of having multiple. partners that can help you. And again you learn different ways to do things. You can offer different things to different people and people may have their niche.
So you may have your partner that's really great reproductive surgeon that you can send someone to, as opposed to in a smaller group, you may have to send them out to a minimally invasive surgeon or someone else. So I think those are some of the nice things about being in these larger practices.
[00:29:25] Griffin Jones: If you had to prioritize those two different advantages that bigger groups have, let's say five or more docs, it being that you have other people to help you cover your patient load, and there's some collaboration there, versus you could go much bigger than that and have, and then you start to get all types of different resources and different types of docs to collaborate with.
If you had to prioritize those two advantages, how would you prioritize them?
[00:29:51] Dr. Sarah Cromack: I think it's a balance. As you start getting more and more docs eventually some people bite butt heads, the more people you have. So I think there's a happy medium. I think I would prioritize having, docs that you feel can cover for you when you're gone, that will, take care of patients like you would hopefully want them to versus being in such a big practice that some of your, some of the docs may not know exactly how you would want to, proceed with some IVF treatment or some FET protocol.
[00:30:17] Griffin Jones: I think that happens at five docs. I think that it happened somewhere, probably around four docs. And I still can't remember where we saw this, but I, it was at an SREI retreat. I wish I could remember the statistic and where it came from, but it was about patient engagement, patient satisfaction, I think measured by number of patient complaints.
And there was a J curve. So it was lower when you had a single one or two docs. I don't think it was by doc. Actually, I do think it was by volume, either patient volume or cycle volume. But the smaller end, the smallest end of the practice is you had fewer complaints and they got more as you got more docs until you got.
Until you got to a bigger practice, which I suspect has something to do with process, but I was more interested in your, in, just in your preference there of a big group practice. You also said that you wanna have some type of involvement with fellows and residents. What type of involvement does that look like?
[00:31:16] Dr. Sarah Cromack: Yeah, I think, not every academic practice or not every private practice won't be involved with, fellows or residents. So you've got lots of different universities that don't have a fellowship but still interact with residents. So I think being able, interacting with residents to me means having residents that rotate with me that sit in with me IVF because there are I A lot of basics I think that every doc needs to know, a lot of my friends that went into generalist practices are doing ovulation induction for their patients.
Sometimes they're doing follicle monitoring. Not a lot of them are doing IUIs, but it's not unheard of to have labs that are not REIs doing that. And so I think there's, at least right now, a lot of my colleagues say they're just learning it from their other partners, but not actually from REIs. So I think we really need to improve our resident education of the basics of REI, not only so people know when to send them to us, also so they know what tests they can order before they send someone to us to decrease that wait time, and so that they themselves can practice, if they want to practice, ovulation reduction in a safe manner.
So I think being involved with residents for sure is something I hope to do whether I'm in private practice or not.
[00:32:27] Griffin Jones: So it doesn't necessarily have to be a faculty position if you want residents rotating in with you, like lecturing at the local OBGYN program. Tell me a little bit more about that.
[00:32:39] Dr. Sarah Cromack: Yeah, I mean, I think ideally that you'll find that job in a faculty environment, but I do think there are so many training programs out there that don't have access to REI. For example, in the Chicagoland area, we, Northwestern is the only fellowship, but there's residencies at Loyola, at UChicago, at Rush, at UIC, and, I don't know exactly how those residents are getting their REI exposure, but they're most likely going to some private practices or going to university based practices not associated with the fellowship.
There are lots of different avenues, and I think even if I was in a private practice, trying to make connections with residency groups in the area to have them come and shadow, and to have them get that exposure opportunity, would be something I hope to do. And I hope lots of people do, because there are a lot of residents out there that need exposure to this field.
[00:33:27] Griffin Jones: We're covering an article about the length of REI fellowship and either side of the debate there. And that article might come out before this podcast episode is there. So maybe some of the audience will have already read it. But it seems to me that there's a little bit of a divide. A lot of people calling for fellowship to be shortened to two years.
Some people, SREI and ASRM saying they're not recommending. the fellowship to be shortened. You are a year and a half in right now. Where do you stand?
[00:34:01] Dr. Sarah Cromack: I definitely stand on the three year camp. I think having that full time for a full year to dedicate to research is very valuable to an REI fellow, even if you don't want to go into research.
So I'm doing. clinical research, not lab based. And I think more fellowships need to offer that to ensure that everyone can get something that they are interested in that year of research time. But, the ACGME has restructured fellowship. So now it's supposed to be 18 months, purely clinical, one year of research at six months elective.
So I think that was a Probably a good change, but I don't think that switch to two years will accomplish what everyone wants. What everyone I think wants from that is to improve the number of graduating REI fellows. The only way we're going to do that is by improving, increasing the number of spots.
So if we go down to two years, if you can add a second fellowship spot. That's great. Then you've maybe increased that number complement of REI fellows we have. Right now, I don't necessarily think that decreasing to two years will also give us that additional spot because a lot of this is, the ability to pay for and maintain that second fellow.
And not every group is busy enough to do that either. So I think we really have to expand the number of fellowship spots we have and also expand the number of fellowships if we can. And that's how we're going to really accomplish what we need to accomplish to get more REIs out there.
[00:35:17] Griffin Jones: Yeah, I guess you would only increase the number of RAIs one year by doing that.
It's like your daylight savings here. Like you want exactly one year, you'd get 88 RAI fellows instead of 44 or whatever it is. But then you'd be back to 44 every year.
[00:35:33] Dr. Sarah Cromack: It wouldn't change unless we add more fellowship spots. And so if you have three fellows. But you're only, it's a three year program versus let's say you have two fellows in a two year program, you would increase it up to four, but you've got, we've got to increase your fellow compliment if that is going to work.
[00:35:47] Griffin Jones: Why is it important to have a research year if you're not going to go into research? It's
[00:35:54] Dr. Sarah Cromack: a good question. I think number one, at least for me on this research year is like the first year after five years that you feel like you can breathe a little bit as opposed to, you've done residency.
A lot of times the first year for us is clinical and you're just busy. And it is so heavy in patient care and you've dedicated so much of your life to, yeah, answer the pagers, you're there for your patients. And it's nice to be able to put that aside for a second and say, let me focus on learning and reading and again, developing my niche and finding what I'm most interested in.
And you just don't have time to do that when you're heavily clinical. So allowing that research here, you're, you not only get more time to study and learn that you. probably didn't have on your clinical years, but you can also develop that niche and find that thing that interests you the most in REI and research it in a way where you can become a content expert in a time where you don't have to dedicate a lot of yourself to clinical duty.
So you get to work, I think, a lot on yourself and your own skill set, and you're just not going to get that if you're doing two full years of clinical.
[00:36:54] Griffin Jones: You have been an interesting focus group of one to talk to today and just see where, to see where your head is at, to see what you're interested in, see what you think is important, and maybe that's somewhat of a bellwether for the rest of your cohort.
Let's conclude, I'll give you the concluding floor with. Either what you think the field is going to look like as specifically as you can within the next 20 years or what you want it to look like in the next 20 years.
[00:37:23] Dr. Sarah Cromack: Yeah, I think I will go with what I want it to look like. So I would love for the field.
Obviously, I would love if we can have insurance mandates in every state. It is absolutely wild to me that we don't cover infertility as a medical diagnosis in a lot of states. And it's. It's just depressing for all of our patients that really can't sometimes access this care. So I would see a field in 20 years where we've got wide insurance coverage for this.
And with, through that, we actually increase access to care so that we are having people's all income levels being able to access infertility because it is present among everybody. So I think that in terms of the field, I REI docs out there. whether that's increasing complement of fellows in each fellowship or a number of fellowships, because there is a huge need for us out there.
And, I think we're going to see new technology. Obviously we are going to, things like gene editing. I think they just approved a gene editing therapy for sickle cell. Will we see gene editing in embryos? I don't know if we'll see that in 20 years, but I think we, I want in the next 20 years us to.
incorporate new technology in ways that is very ethically responsible. And so I hope, whether I'm part of ASRM or other future groups that we are making sure we have guidelines that allow us to move this field forward in exciting ways that are really helpful for patients, but that are, taking care to make sure we were doing it in an equitable and ethically sound way.
[00:38:50] Griffin Jones: Dr. Sarah Cromack, I've enjoyed getting to hear where you are in the earlier part of your career. I hope to have you back to, to check in on you from time to time as you continue to advance in your career. It's been a pleasure to have you on Inside Reproductive Health.
[00:39:04] Dr. Sarah Cromack: Thanks so much, Griffin. It was great talking to you.
And yeah, I hope to come back maybe in five years. We'll see where I am at.
[00:39:10] Sponsor: This episode was brought to you by Prelude Fertility, where top REI physicians find their calling. Practice anywhere with Prelude. The Prelude Network is the fastest growing network of fertility clinics in North America. With more than 90 plus locations, we're ready to support you and your individual career aspirations wherever they lead. To learn more, please visit rei.preludefertility.com. That's rei.preludefertility.com.
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