58 - From Fellow to Partner: Advice for New Associates and Growing Practices, An Interview with Lowell Ku

Listen on Google Play / Apple Podcasts / Spotify

Large practice networks and groups with private equity backing are becoming more and more attractive to new REIs coming out of fellowship. Is there still a draw for new doctors to join smaller, independently-owned practices? On this episode of Inside Reproductive Health, Griffin talks to Dr. Lowell Ku, Senior Partner and Medical Director at Dallas IVF. Dr. Ku left fellowship with a plan to join academia, but was quickly drawn into being his own boss at a small privately-owned clinic. Dr. Ku shares his story about why he chose this path and offers his advice to new fellows who are searching for answers to determine their own path in the fertility world. 

Learn about Dr. Ku and Dallas IVF at dallasivf.com. 

To get started on a marketing plan for your company, complete the Goal and Competitive Diagnostic at FertilityBridge.com.

***

Welcome to Inside Reproductive Health, the shoptalk of the fertility field. Here, you'll hear authentic and unscripted conversations about practice management, patient relations, and business development from the most forward-thinking experts in our field. 

Wall Street and Silicon Valley both want your patients, but there is a plan if you're willing to take action. Visit fertilitybridge.com to learn about the first piece of building a Fertility Marketing System--The Goal and Competitive Diagnostic. Now, here's the founder of Fertility Bridge and the host of Inside Reproductive Health, Griffin Jones.

GRIFFIN JONES  0:54  
Today on Inside Reproductive Health, I'm joined by Dr. Lowell Ku. Dr. Ku is an award-winning, nationally-recognized, board certified REI and Reproductive Surgeon. In addition to being a Senior Partner Medical Director at his practice, Dallas IVF, Dr. KU serves on the board for the Society of Reproductive Endocrinology and Infertility--SREI--as well as the Patient Education Committee and the Technology Committee at ASRM. We're going to talk about that. What I didn't know is that Dr. Ku also struggled with infertility and overcame that. He's committed to providing compassionate and personalized care that comes from both his medical training and his personal experience to help his patients achieve pregnancy rates are consistently among the highest in the country. But doesn't everybody say that? Welcome to the show. Dr. Ku, Lowell. I'm happy to have you on.

LOWELL KU  1:46  
Thank you, Griffin. It's just an honor and just such a privilege to be part of the show. Thank you so much for inviting me on.

JONES  1:51  
Well, first off, I thought we're going to talk about being part owner of a private practice and being a partner and I thought the whole thing about private practice was that they don't have time to be on things like the board of SREI and the committees at ASRM. So what's going on with that?

KU  2:09  
You know, it's also an honor to be able to serve my community and the organization of American Society of Reproductive Medicine just kind of be able to give back to the organization that gives to us. Yeah, it does take a lot of my time, but it's time that I make time for. So it's something that's so important to me--be able to give back, to be able to contribute to the organization that helps, you know, support us. So, for me, it's super important.

JONES  2:34  
So talk a little bit about how you found yourself in private practice then because you're still a relatively young doc. And I would maybe venture that a lot of people who want to have that as part of their career path--sitting on committees at ASRM, being on the boards of other societies--would drift toward the Academy. How did you end up in private practice?

KU  3:03  
Absolutely. You know, when I was going through fellowship, my main thought was that I was going to be an academic, a teacher, a professor and teach fellows. I mean, I still love to teach, but I absolutely loved it when I was in residency training to teach the younger residents and teach the fellows when I was a fellow--the younger fellows--and so it was awesome. I love still teaching and seeing that sort of excitement from learning in the students’ home. So for me, I thought I was going to be a full-on academic. And then as fellowship sort of went on, I started to think you know, I think I'd like to try private practice first and and see how that goes. And so I explored that opportunity for private practice and sort of found my way into the practice that I'm in today at Dallas IVF.

JONES  3:49  
And so what attracted to you about becoming a partner at the practice because I thought that younger REIs are said to be not entrepreneurial, that they don't want to take over partnership, they don't want to buy in, they want to go work for a large network and collect their paycheck punch in, punch out. I don't believe that, which is why you're on the show, and we're talking about it. But that's said enough. So what was it that attracted you to actually becoming someone that's at the helm of the organization?

KU  4:11  
You know, I think it started actually, when I was a little boy. My dad was a dentist, he's in solo practice in dentistry, still practicing, although he's about to retire. You know, he, he told me when I was a kid, he said, “You know what, you should be your own boss. And you should be able to be the captain of your own ship.” And I said, Okay. And that sort of stuck with me as a kid. And, to me, that's kind of how I viewed the practices that I was interviewing with. I wanted to see, you know, which practices could I join where I could grow with that practice and grow the practice along with my own practice into a larger, bigger practice where I could be very proud of the services that we offer, to be proud of the practice that we built, and to be able to be actually one of the bosses of my own destiny, so to control my own destiny. And so I worried that if I were to join, let's say, like a bigger corporate practice, I'm worried that I wouldn't have that control over my own practice. I'd worry that I'd always be an employee. And that just wasn't something that I kind of saw for myself in the future. So that's why I decided to join Dallas--I get to join a practice where I was like, “Okay, I think I can grow this practice and grow my own practice into something bigger.” And when I joined my practice, it was just me and the other partner and so it's just two guys just kind of starting with practice and building it up. And now we have six to seven physicians, and we are hopefully continuing to grow.

JONES  5:52  
So I want to jump back to that part about the employee because I think that's something that's still unfolding of seeing what it's like to be an employee for a much larger group, or a partner at a group who also has a lot of their equity owned by a private equity firm or some other network. Let's talk about how the practice actually got started because I always thought that it's more common to see a practice that starts off with two or three docs grow to the 5, 6, 7 doc practices than the solo doc that goes 1, 2, 3. How was that trajectory for you all?

KU  6:38  
You know, when we first started, we were the two docs and then one of the hardest things was to really be ready for the third doc. Both of our practices had to be full-steam ahead, up and running before we could really feel comfortable adding a third one. But once we ended, the third doctor, the fourth, and fifth, and the next ones after that were a little bit easier because we started to create a template on how to get it a practice going, how to get an associate busy, and what were the most important things to associates in terms of their practice and their futures. So we kind of created a little template that we kind of follow for the subsequent associates. And that's worked fairly well for us. And so for me, that was the most important was to be able to drive the ship, be able to be the boss of my own practice, and not have to worry about, maybe, having somebody look over my shoulder and tell me that maybe I need to be more productive, or maybe somebody telling me that I can't take that vacation to go see my daughter's recital. I just--I wanted to be my own boss.

JONES 7:34  
Were you the second doc in then?

KU  7:37  
I was. I was the second one in with this.

JONES  7:39  
And how long had your partner been in practice in the market before you joined?

KU  7:45  
Yeah, so he had been in practice for literally 10 years before I joined. And at that time in Dallas, there were probably about 10 to 11 infertility guys and practitioners here in town. And when I joined, I was number 12. And since then, there has been a deluge of docs. And we've been fortunate that we've been able to choose from the people that want to come here to Dallas and to have them and ask them to join us. And we've been fortunate that they've wanted to join us. But yeah, he was here for 10 years first then I joined him. And then after that, it was about four years and then a third one joined. And then it was three years after that, the fourth one, and it was literally like two years, the fifth one and then a year later, the six and seven. So we kind of figured out what the model should be like.

JONES  8:32  
So do you just look so much younger than I actually think you are--then you actually are? I just think you're so much younger than you really are? When was this that you joined? What year was that?

KU  8:45  
So I'm very honored that you think that I'm younger, but I am a little bit older. I was--I started saying--I started the practice with this practice in 2008 after I graduated fellowship. So I had been doing this for a little while and it's taken me a little while to kind of get the practice up and running and get the whole big organization up. So yeah, I graduated 2008 fellowship.

JONES  9:06  
So then there's a four year that you join, there's four years before doc number three comes on? And then a few years and then it seems like the interval just decreases by 50% each time. I wondered this because I see right now--particularly in small markets, so I don't know if this applies as much to large, fast-growing markets like Dallas--but in small markets, I'm seeing a real hard time of the single practitioner, even attracting another doc. And so I wonder if, do you think that at the time you joined, do you think that that was different? It was more common to join up with a single doc and maybe that ship has sailed for some people. It's just harder to do that now?

KU  9:54  
I totally agree. So, first, you know, to address your thoughts about how some small towns may have difficulty attracting associates--and that's totally true. A lot of my colleagues from smaller towns--not smaller as in like small, small towns--but towns that are smaller than Dallas, they call me and they said, you know, we're having a hard time finding people coming to our town to just join our practice. So I feel for them. And so in Dallas, it's sort of the opposite. We have more than enough people coming and the practice luckily gets to choose from the people that are coming, but Dallas really has become so competitive with so many incoming fertility specialists when they graduate from fellowship. So it's gotten very competitive here in Dallas. Now we have I think, around 30 to 40 and fertility practitioners here, when I was number 12. So it's been a struggle to kind of maintain market share. And the other thing that you had mentioned was that you know, is that are those days of just hanging a shingle--are those days gone? I, you know, when I graduated from fellowship, I was worried that would I be able to make it if I just hung a shingle? There's so many things that I just didn't understand about starting a practice about the business of medicine and practicing medicine and like how do you open up a lab? Open up a surgeon? And these are things that really kind of scared me and I wasn't sure that I would be able to do it by myself. So that's why I was looking for a practice that maybe was a smaller one where I could join them together, we can pull resources and knowledge to grow the practice.

JONES  11:20  
And so what was that transition like going from a practice that had been in business for 10 years with one principal at the helm to now having--I assume you started off as an employee, but then a partner--what was that transition, like going from one to two?

KU  11:39  
You know, as a fellow we never ever get any sort of training or teaching on on partnership. They never tell us about the business of medicine. And so partnering was always this sort of mystery that was shrouded in secrecy that no one ever, sort of, talked about. So I'm really glad that we had this opportunity today to really put a voice behind and to really to kind of take back the curtain and show people how it works, at least in our practice. So the way it works is when you start in our practice as an associate, you're an employee. And typically in Dallas, it takes about three to five years before your practice is pretty mature and that you're humming along seeing patients. So after the first year, we know that the business is going to be able to basically support that associate and the second year we think that associate might be able to support themselves and then the third year, we think the associate is going to take off and then they should be able to partner after the third year at our practice. Some of our associates haven't been able to partner after three years, but that's okay. They partner at the third year and a half or maybe at the fourth year. So we're very open with our associates. We show them from day one, how they're performing within their business--in our business model, in our business plan. We show them the numbers, how are they performing and then we kind of let them know that they can hopefully understand that, Okay, I need to maybe market myself more, try to build my practice even more, so they can understand how it works. So we'll support them for the first three years and then once they partner, then they can enjoy some of the headaches that I have as a partner!

JONES  13:06  
Which was the more difficult transition going from one to two or two to three?

KU  13:11  
I think two to three for us was the tougher transition because from one to two was sort of easy because he was--the senior partner was so full of patients and busy. He was actually turning away patients, so he was losing business. So he thought, Well, maybe we can have a second person to sort of capture that, that business with the practice. And then once I started coming on board, it took a little longer for me to get started just because more and more fellows were graduating and coming to Dallas, and we were competing with each other and so it slowed us--slowed me down a little bit. So to go from two to three was harder for us. 

JONES  13:44
And then, and not just in terms of volume of building one's own practice, but just in terms of the structure of the organization, do you feel that you know there's a real shift from--is it two to three that is the biggest is it four to five? And now you're at seven so you've got a bell curve to analyze--where do you think structurally operationally, you really start to see, okay, we need to have different systems in place now? 

KU 14:08
Absolutely. The infrastructure that we had built now really started to come into play in that we needed it around the after the fourth one was hired. We really needed to have an office manager that understood how to run a bigger practice. The office manager that we had at the time was with the practice for a long time, but she wasn't sort of experienced to run a larger practice that we had to find someone who had more experience. So we had to build this infrastructure. So we had to find a practice administrator, as well as an office manager, as well as financial counselors and coordinators, and actually marketers--we started to hire marketers. And so the infrastructure really started need to be formally founded after the fourth one was hired. 

JONES  14:50
Did you know that you wanted to be in Dallas because you saw this type of growth trajectory in a market like that? Were looking at a few different markets? Were you open or were you pretty set on Dallas? 

KU  15:04
You know, my parents and family are here in Dallas and I'm from Dallas--born and raised in Dallas. So for me, Dallas was where I was really focusing. My wife is from Houston, so it was either Dallas or Houston for us. You know, I interviewed in a number of places around the nation, but when we landed in Dallas and I stepped off the airplane, got into DFW Airport--which is crazy-- it felt like home. And for both me and my wife, we felt like this is where we want to be. So it was just sort of this sort of feeling and an emotion that hit us when we landed in Dallas and said, you know, we want to be--I always say that Texas is crazy, but it's my crazy.

JONES  15:39  
Fair enough. And a market like Dallas is a very interesting one just because it has been growing so quickly for so long and doesn't seem to be slowing down. And so you knew that you wanted to be there also made sense as a place to build up your practice and you talked about it took you maybe three years, let's say to build your practice--somewhere between three and five years to really build your practice to the way you wanted. And that's sort of what associates can expect in a market like that. Speaking more broadly, maybe not specific to Dallas, but what sorts of KPIs need to be agreed upon for the associates so that they know and the partner knows, this is what we're going to say you're eligible for partnership after this or not. I've talked about it on previous episodes, I've interviewed people on the blog, and I've just talked with partners and I've talked with associates who said, Yeah, they thought they were going to be partner. There's no way they weren't pulling their weight. And then I've talked to associates and said, You know, they totally screwed me over. And the common thread between both of those conversations is there was not something that was really finitely defined and agreed upon in terms of key performance indicators that says if you meet these metrics, then this is what makes you eligible for partnership that we can both sit down at the end of and say, where they met yes or no objectively. And so, broadly speaking, what do those need to be? What needs to be in writing? 

KU  17:15  
You know, that’s the perfect question. When I first started here, there were no KPIs. I think the the senior partner was just kind of like running by the seat of his pants and I didn't really know and I was naive at the time. And so I just thought, I'm just going to throw the practice and then I'll partner. And so we, over the years, we've developed these KPIs, and one of them is to sort of match the growth of my practice when I first started, which I'm like--I don't know if I'm the perfect model for that, but we want to see this sort of trajectory of growth in seeing the patient volume, revenue, billing collections, all those things. And as long as they're sort of meeting that sort of benchmark each month and it’s growing according to the sort of the graph that we have. And now we have six or seven lines on the graph, and we say, Look, as long as you're running in these areas of the graph, then you're set to partner. And that's kind of how we run it in our facility. And rightfully so, we want to make sure that when the partner--or when the associates are ready to partner, rather, that they're not going to struggle. I know when I actually partnered, my payment dropped because I now had overhead and I wasn't quite collecting the amount that I needed to support myself, so it was a bit of a struggle for the first years after partnership. And so we don't want that for our new associates and our new partners. We want to make sure that when they partner that they're going to fly on their own and they can support themselves.

**COMMERCIAL BREAK**

Do you want your IVF lab to be at capacity? Do you want one or more of your docs to be busier? Do you want to see more patients that your satellite office before you decide to close the doors on it? But private equity firms are buying up and opening large practice groups across the country and near you. Tech companies are reaching your patients first and selling your own patients back to you. And patients are coming in with more information from the internet and from social media than ever before--for good or for bad. You need a plan.

A Fertility Marketing System is not just buying some Google ads here, doing a couple of Facebook posts here. It’s a diagnosis, a prognosis, and a proven treatment plan. Just getting price quotes for a website for video or for SEO, that's like paying for ICSI or donor egg ad hoc, without doing testing, without a protocol, and without any consideration of what else might be needed.

The first step of building a Fertility Marketing System is the Goal and Competitive Diagnostic. It's the cornerstone on what your entire strategy is built. You don't have to, but it is best to do that before you hire a new marketing person, before you put out an RFP or look for services, before you get your house in order, because by definition this is what gets your team in alignment. Fertility Bridge can help you with that. It is better to have a third party do this. We've done it for IVF centers from all over the world and we only serve businesses who serve the fertility field.

It's such an easy way to try us out. It's such a measured way to get your practice leadership aligned and it's a proven process to begin your Marketing System. Without it, practices spend marketing dollars aimlessly and they stress their teams and they even lose patience and market share. Amidst these changes that are happening across our field and across society, if you're serious about growing or even maintaining your practice, sign up for the Goal and Competitive Diagnostic it’s at FertilityBridge.com or linked here in the show notes. There is no downside to doing this for your practice, only upside. Now, back to Inside Reproductive Health.

JONES  20:26
Those six indices on the graph, do you enumerate them in the employment agreement that if you're within this axis of the graph, this is what makes you eligible for partnership after employment?

KU  20:41  
We don't actually enumerate as in like, this is the amount you must be billing for or collecting, but maybe we should actually because these KPIs are very important because if the associate does feel like they're--that they think that they should be able to partner, but then we should look at the numbers and say that they really can't. That's this sort of disagreement is concerning for us. So we want to make sure that we make sure that's a nice happy agreement. So I think that for us, we don't have it enumerated, but we maybe should do that.

JONES  21:07  
I think that it’s something that's missing in a lot of independently owned practices. But you're further ahead than many and I think it seems to me that the risk that you took in 2008 of yup, we're just flying by the seat of our pants, and then we're going to come up with benchmarks if we both think it works. I mean, that could work out, I just don't see nearly as many people eager to do that in 2020 as they were in 2008, especially when there's so many networks and large groups that can say, here's the track plain and simple. Here's the agreement, plain and simple. To me, it just seems like less of a risk. Did you feel like you were taking a risk in 2008?

KU  21:56  
I did. I definitely felt like I was taking a big risk that if my practice didn't take off, I would have to find another place to go. And so it was worrisome to me. But the part of that was the drive that helped drive me and it was sort of this the fuel to the fire that allowed me to work even harder to try to make sure my practice survived.

JONES  22:15  
I wonder, did you also look at practices where the doctor was going to retire within five years--that the current single physician owner was going to retire and they'd wanted to sell to a new doctor? Did you look at any of those options?

KU  22:32  
I considered those options, but my worry is that I didn't know if I could afford to buy a practice that was so busy. Coming out of fellowship, I didn't have any money, I was dirt poor! And so I worried that I wouldn't be able to afford something like that. So I wanted to join as an employee first and kind of get my feet wet and then partner. So that's kind of how I did it.

JONES  22:52 
We've talked on this show before, some groups have structures in place where they don't get too top heavy. I mean, we've already established that you're going to look like you're 60 when you're 110 and if anybody's gonna outlive the rest of us, it might be you! Is there a point where Lowell has to sell his equity and and phase out at a certain age? Do you have any structure like that? I have noticed that in groups where there's four partner docs and they're all around the same age, that it makes it just too top heavy for a younger physician to buy in. There's more distribution in your ages. But is there any kind of system in place that prevents you all from getting too top heavy?

KU  23:41  
We don't have a mandatory sort of retirement clause in our contract. However, I don't know--my dad is 78 and he's still working! I'm thinking I might work until I’m 78, too!

JONES  23:57  
I'm shaking my head yes, because I can see that. I also see other practices where it's just--it's that the older doc is not maybe even doing retrievals anymore, or they're seeing far less patients, but their share of equity is still either the greatest or certainly greater than what it is relative to productivity, and there's trapped equity because of that. They haven't phased out appropriately, so their share is top heavy, and makes it nearly impossible for a younger doc to buy in.

KU  24:32  
You're absolutely right, when there's only a certain limited number of shares, and let's say the initial guy has most of those shares, it's definitely difficult for the younger guys to even make it worth it for them to even partner. If they're only buying in, let's say 1% of the practice, then it's not may not be worth it. So, you know, we have we've had these discussions in our practice as well and we talked about how if the practitioners practice is waning, and that they're not pulling their weight--now we haven't defined it is--that they will probably have to relinquish or sell their shares back to the practice. So I think that this is something that all practices should definitely talk about and it should be an open discussion because you're right if the practice doesn't have these discussions, they'll find themselves too top heavy and then it makes the practice uninviting for new associates.

JONES  25:21  
Your dad planted the seed in your brain from a young age of being your own boss, you've mentioned that a couple of times as being part of the ethos of why you want to be a partner not join a larger network, but I know the optics of a practice like yours and others in the market--I've got to give Ravi Gata a shout out because I know he'll give me--I know that Dr. Gata will give me grief if I don't give their group of mentioned with Dr. Gata and Dr. Chantilis and their partners--but a practice like that a practice like yours. I know the optics of practices like that where the single physician small market practice owner really isn't getting too many calls from private equity firms. They have far fewer exit options. A 5, 6, 7 doctor practice in a market like yours that is growing 10,000 people a month in the metro, that looks really good to just about any network, to any private equity firm that isn't in the field yet that wants to break in the field. I imagine that you get a lot of calls. And how does the ethos of being one's own boss stack up to some pretty attractive offers I imagine?

KU  26:36  
Yeah. Now first love Ravi Gata, love Sam Chantilis, love that group, they are awesome. You know, if we could only one day decide to join forces that would be great! But that's my plug for that.

JONES  26:48  
Okay, well, I want to be a part of that deal. If your partners are listening and their's, then the negotiations started right here on this show!

KU  26:57  
Absolutely! If that could happen, that would be a dream come true for me. And so, but yeah, you know, I think we have been contacted by quite a few VCs who are interested. At this point in time, I think we're still in a growth phase, we're not quite ready to sell. I think right now we want--and if we did decide that we were going to turn over the reins of the practice, it'd be a sad day, I think, because I've always wanted to be the boss of my own practice, and I'd be worried about that. But it would be that all the partners decided that all these associates have partnered before we sell, so we don't want to leave any associate stranded.

JONES  27:33  
And so that’s really a noble thing to have with the doctors that you’ve brought on your team. Do you have a buy-sell agreement then because if being one's own boss might be worth X to me, but it might be worth Y to the next partner. And so, do you have a pre-planned agreement that says okay, if once we are all partners, if these criteria are met, we agree that we're going to sell? Because I think that's a hard decision for one proprietor to make much less for seven to be in consensus!

KU  28:12  
You're absolutely right. And having spoken with my colleagues around the nation who are in this position where they're like seven or nine physician groups, and they're in the process of selling, I have heard a lot of headaches that have occurred where the partners cannot agree on the terms of the sale. So we don't have a specific buy-sell agreement, but we do have discussions ongoing about when do we think we might be ready. The first thing was always well, we feel that we would be ready if we are less in a growth phase and all the partners are partnered--that we won’t have any associates--but I worry that there's gonna be a lot of ongoing discussions at that time, if that time even comes for us, that we may not agree on everything.

JONES  28:51  
You've gotten used to being your own boss at this point. What would you want to make sure that you hold on to? And I don't think that this can be understated or at least considered in the overall cost benefit of selling equity, which I asked two different people this week to come on the show that have sold equity of their practice. And they said, Yeah, well, we talked to the lawyer and we think that we could come on, but if anything, were considered disparaging, you know, I just can't talk about this. And they'll say, you know, We can't choose our marketing firm. We can't choose our office supplier who we buy pens from, we can't make decisions about if we want to have a baby reunion and we don't have total personnel control like we used to. For me, at those words alone, I can't come on a podcast, makes my price go up 25% of whatever it was. But for you, what is the most important control that you would need to hold on to?

KU  29:57  
You know, for me, it would be making sure that I can still take great care of my patients. That's the most--that would be the most important thing is that I want to have still the autonomy to say, Okay, if I want to do a laparoscopy, I want to do this procedure--that I will be able to do that and that the bean counters aren't really breathing down my neck saying No, no, you got to do this procedure because that's more lucrative. That's what I want to make sure that I want to still be the doctor, I want to be able to take care of our patients the best that I can. So that's for me to number one.

JONES  30:24  
What would you say to someone just leaving fellowship right now or maybe they're finishing up a two-year employment agreement, and they're not going to become a partner at their current practice or they're not going to stay in academics, they're looking at larger groups, maybe they can take over for a solo doc, maybe they can join up with a solo doc, or a privately-owned group like yours that has multiple partners. What would you want them to consider?

KU  30:53  
I’d want them to consider first, are they a good fit for our practice? And are they going to be like minded like all the rest of our physicians and associates and partners, which is meaning, are they going to want to be able to propel their own practice number one, and will they propel the bigger practice as a whole, to elevate it to make it stronger, bigger, and better so that we can reach out to more patients? So I think that's the first thing is, like do you fit with the practice that you're looking at? And if it's ours, and you fit our practice? I think the second thing would be like, well, what is it that you're looking for in a practice? Do you want to practice where you want to build a partner? Or do you want to join a practice where you can just maybe have the the luxury of just being an associate or an employee, you don't have to worry about hiring and firing and all the headaches that come with partnering? And those are the two things I would definitely start out with. You know, recently we had a physician join us who was already in private practice in town and so it's been a nice union for us both because this physician brought in some of her patients in her busy practice and we were able to provide infrastructure for her so it's been a nice union.

JONES  31:58 
I was thinking of concluding, but I want to ask you a tough question about mid-size practices. Is it alright if I do that? 

KU  32:06
Yeah!

JONES  34:07
And you could say your practice is a large practice, I mean, you are one of the largest, if not the largest in the fourth biggest market in the country--so you could say that Dallas IVF is a large practice. But if we're just talking about groups that are in multiple cities and have dozens of physicians, and then we're comparing that to two doc, three doc, single doc practices, just for the sake of this, let's say that it's a mid-size group. I've heard other people in the field say, I've experienced sometimes, that sometimes a mid-sized group is the worst of both worlds in certain operational senses because they don't have the the C-suite infrastructure that the largest groups do, where there's a CEO leading and they've got a Chief Human Resources officer, and a Chief Revenue Officer and a COO that's keeping everything in line and then the docs are sort of on a board and everything thing is established and sometimes there's private equity, sometimes there isn't. They've got the resources and the infrastructure. And then, you know, I also see people that run successful practice, single doctor practices, with seven people in their office because they're that lean. And when you're that lean, there's not multi-tier management, there's more forgiveness when you don't have systems and uniform processes in place. Whereas when you start to get to four or five doctors, you're not in that place where you have all the infrastructure and the resources, but you do have a lot of the problems of growth. How do you deal with that?

KU  33:41  
You're absolutely right. We are sort of in this phase of our practice where we are in a growth phase and we are suffering some growing pains. Absolutely. We're not large enough to really require a C-suite yet, but we're getting there. And so that's we've been talking about well, does our practice administrator now become our CEO and then do we hire another person who becomes our CFO? And so it becomes this sort of discussion like, well, are we ready for that? Or do we have the funds for that? Another thing that we find that is a bit of a difficulty in our--in this sort of size practice is that well, we don't really have senior positions that are behaving like managing positions yet. So it's sort of like we all, in our practice, everybody has an equal vote, which is great, but sometimes those votes don't add up to a majority and they're all different votes. And so I think that in larger practice where you have, like you said, the practice of 20 doctors in different countries, what that they probably have these sort of managing partners, then you have the C-suite, and they have a system that's already set so that the younger guys can are like, hey, look, this is how it works. Here, we're sort of developing our own system. And we are looking to the bigger boys to see okay, how are they doing it? How are they managing it? And we are sort of modeling ourselves rather after those guys.

JONES  34:52  
Well, you are certainly an example of a mid-size group that is growing quickly, that has grown from small to mid-size pretty quickly and on the trajectory to being a large group. You're also someone that came in out of fellowship, bought into a practice that was established, and did what a lot of single physicians in smaller groups would like to promise younger doctors that they're recruiting. You’ve actually done that. You've gone, you were a second doc, you've grown to seven, you're 12 years out of fellowship at this point, you've got this going. So how would you want to conclude with our audience about the future of independently-owned practices, and how younger docs might see themselves fitting into that model?

KU  35:41  
I would recommend to all fellow graduates to take a very good look at an independent practice that is growing, mid-size practice as well, to see if they could fit in because what we don't want to do is relinquish all of our autonomy to the corporations. I worry that if we do that, we may not be able to control our own destinies. And for me, one of the big things that I wanted for my life was to be able to determine my own destiny. And so I worry that if they don't look at the independent practice or join an independent practice, they may not have that ability to have a say as to their future.

JONES  36:19  
I would add to that, ask is there anything that would preclude me in coming on Inside Reproductive Health and speaking my mind and if they say yes, there is something that would preclude that, then run away!

KU  36:30  
Exactly right!

JONES  36:33  
Dr. Ku, Lowell, thank you so much for coming on Inside Reproductive Health. 

KU  36:36  
Thank you, Griffin. It's been an honor and a pleasure. I really appreciate it.

***

You’ve been listening to the Inside Reproductive Health Podcast with Griffin Jones. If you're ready to take action to make sure that your practice drives beyond the revolutionary changes that are happening in our field and in society, visit fertiltybridge.com to begin the first piece of the Fertility Marketing System, the Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.