On this episode of Inside Reproductive Health, Griffin talks to Dr. Kenan Omurtag of Washington University in St. Louis, Missouri. Dr. Omurtag shares what he views as the pros of working in an academic clinic, as well as the downsides to working in an academic system. They also discuss the history of the model and what it will look like in the future as the world of fertility continues to grow.
2005 Article from Fertility and Sterility on Academic Medicine
The Ultimate Guide to Fertility Marketing
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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 0:55
Today on the show, I'm joined by Dr. Kenan Omurtag. Dr. Omurtag is a dual board certified doc in both OB/GYN and REI--takes care of all things related to pregnancy, infertility and reproductive hormone issues. His normal day consists of minor and major surgery cases, diagnostic testing, and procedures such as IUI all the way to IVF to retrievals and embryo transfers. His practice focus includes PCOS, unexplained infertility, male infertility, recurrent pregnancy loss, third party, and--
DR. KENAN OMURTAG 1:31
What’s left?!
JONES 1:32
--advances and treatments. If there's something left, we're going to have to uncover it in the show! Dr. Omurtag, Kenan, welcome to Inside Reproductive Health.
KENAN OMURTAG 1:40
Griffin, thanks. It's an honor to be here. I've really admired what you've done with this platform.
JONES 1:44
I appreciate that! What I didn't include in the intro is part of our focus today, talking about the academic practice, because I come up with guests and topics for the show very often when I'm at one of the meetings and I run into someone that I haven't seen in a while and I think, Oh yeah, that's something I need to talk about and that's a person that I need to interview. And on my show because it is focused on the business side of our field, I have left out the academic centers in much of that conversation. I've only had a couple episodes with guests from academic centers on the show and you're one of the very first--I’ve scheduled a few more--but I ran into you and we started talking about this and I wanted to talk about the future of the academic center and how it is today. And maybe to get to that I'm interested in why you decided the academic route as opposed to partnership at a private practice, as opposed to employment with a large network.
OMURTAG 2:53
Right. Well, I mean, first of all, again, great to be here. I mean, it's been really fun kind of watching your rise in this space. So it's really cool to talk about this topic. I mean, I think if you want to just jump right in, I mean let me jump right into it! If you want to understand where the future of the academic medical center is in reproductive medicine, I think it's important to kind of look at what the history of the academic medical center is in reproductive medicine to understand kind of how we got to where we are. So just for example, you know, one of the first IVF cycles in this country was done with the Joneses at the Jones Institute, an academic center. A lot of the innovation in early ART was in the academic center. Prior to the advent of ART, it's important to point out that reproductive endocrinology and infertility was actually an OB/GYN boarded subspecialty, but it was called reproductive endocrinology and then the infertility was kind of like a lowercase “i” and the reproductive and the endocrine were kind of like the capital letters and kind of drove a lot of the focus of the subspecialty. So in the late 70s, the specialty of reproductive endocrinology was largely focused on steroid hormones, steroid biosynthesis. How do you actually measure an estradiol level, an LH level, an FSH level? And how do you do it effectively in a timely fashion to help augment, among other things, fertility care? But there was also an emphasis on medical endocrine things. But when IVF became a reality in the early 80s, and a practical reality at that, there became somewhat of a schism. Let's also not forget a lot of reproductive endocrinologists were the early laparoscopic surgeons. So what you have with ART is, Oh, we can do this? Oh, there's this divisionary of people who kind of said, Okay, I think this is going to be big. We should invest in this and we should still be REI, but we should maybe focus on the “I” a little bit more, because quite frankly, no one's gonna pay us to take care of patients. I mean, there are medical endocrinologists who take care of patients with diabetes and thyroid issues and all these other things, where our space is probably better suited for this IVF ART thing. So that's where I think the divide starts to happen in the 80s. And then it kind of goes--
JONES 5:17
As the divide is happening, does that mean that you chose one of the forks in the road or at least--not that they're mutually exclusive, but that they do have different focuses and you wanted more endocrinology in your practice area? How did you make that decision?
OMURTAG 5:42
Well, to me--so I became interested in Fertility Care in 1996. When I was a freshman in high school and I took a class on genetics, I did a nerdy summer camp, I guess, at Duke. Shout out to the TIP program at Duke University and at the time, they had cloned Dolly, they were talking about gene therapy. And I was like, Oh, this science is fascinating. What's the future medical application? Or what's the medical application because I didn't want to be a science--like a basic scientist, I wanted to be a physician. And IVF was like, oh, this is a clinical application of the frontier of science. Let me explore that. So it was actually the in vitro fertilization, the future of reproduction, that is what attracted me to the field. So in essence, it's kind of the IVF component. The surgery component, the endocrine component didn't really mature until I went into residency and I understood more about the field.
JONES 6:42
And so now we're at a place, however, where I see that differentiation in practice areas, but I also see, maybe, is there a reconvergence as well? Because to me, it seems that some academic centers are also really powerhouse IVF centers. So is that more--is that still just further stratification of the differences that we have? Or is there a reconvergence because of its practicality and also probably because of its financial impact?
OMURTAG 7:20
I think is a combination of both. A lot of--so, honestly, the ability to move egg retrievals outside of an operating room into, like, an ambulatory setting is what moved IVF out of the academics. You didn't need to be in this kind of, like, hospital setting, you just needed to be in an ambulatory center. And then this is the late 80s/90s people are kind of managed care is changing. Physician-owned ambulatory centers are popping up as a result. So you have all this, this new delivery care and IVF and the visionaries who were like this is big, we need to do this, are the ones that were were also able to either politically or through their ability to influence their local hospital leadership to help support the new delivery model of this ART fertility care service. So I think what we're seeing now is we're seeing the academic centers are trying to figure out, I think, people are recognizing that there's a niche that in an academic center that can be had. And one of those niches could be, quite frankly, the fact that these academic medical centers have their own employees and their own self-insured policies. And there might be opportunities for academic medical centers to provide benefits that are exclusive to their fertility clinic center, allowing them to kind of provide immediate market to their own clinic. So I think--just kind of meandering back to where the academic medical center might find future benefit--it could be there.
JONES 9:00
Well, I want to talk about that future benefit, especially related to the prospective physician employee, and pick your brain about some of the pros and cons about working in academic center. And I can think of a few! And I want to see what readily comes to your mind and then I want to further explore them.
OMURTAG 9:23
Not all academic centers are the same. I think that's the--I mean, honestly, not every private job is the same. They're all very different. But the pros and cons of academia, in medicine, mirror largely the pros and cons of academia of other industries. You know, in medicine, when you're in academia, the primary goal is to do some sort of academic pursuit, whether that's educating or doing some research. And when I say doing research, that's actually you're getting paid to ask--you're relying on grant funding to pay the majority of your salary. That is an opportunity for academia. When you're in private practice or when you're in any industry, your source of income is your labor as it relates to clinical care. There's a lot of that in academia and the nice thing about academia is you can have people who, I just want to focus on clinical care and that's how I want to get paid, but I want to have an opportunity to kind of maybe dabble in these other things. So and I think that's what attracts me to this kind of model is, really good at seeing patients. I can see a lot of patients. I'm efficient with my time, but I can also make time to do stuff with medical student education, resident education, and then every now and then I can dabble in a research project that I don't have to worry about getting grant funding, but I can incorporate in my routine, so it gives me variety.
JONES 10:51
What I would like to find the answer to--or better said what I'm interested in to just see what plays out in the next 15 years or so is how millennials and Gen Z shape the nature of or the routine of what happens in the academic practice. Because I want to share one of the cons that I see is very often the autonomy of the division--of the division chief is so limited with what goes on relative to the rest of the health system. And it's so bureaucratic that they get very little special attention. If they do get extra attention, it's often top down. They often can't even make decisions on very--on starting an Instagram channel, for example, or they want to do a Facebook Live event. Someone needs to sign off on that, right? So I see it all the time when I'm talking with division chiefs, and I just don't see millennials and Gen Z employees and physicians are taking to that. So are they going to change the bureaucracy of the system? If that is the case is going to take a long time? Or are they just going to say, you know what, I can get a lot of these benefits working for a larger fertility network, and I don't have to deal with as much bureaucracy. And are the academic centers gonna lose out because of that?
OMURTAG 12:26
I think there's a threat that they will--that they could lose out on talent. So that's something that has to be that is something I'm very sensitive about. The question is, though, what like, what is the mission of the academic department? What is the mission top down? And where does the reproductive endocrinology and infertility division fit in that mission, and that is always subject to change kind of on whim sometimes, it feels like. But also if you're just looking for, like, hey, I want this job. I want to just see some patients, a bunch of patients. I want to be around some collegial people for a couple years, I'm going to build my brand on Instagram by myself where I'll have more flexibility to talk freely without having to get any approval. You can do that in academia. If you want to manage--so I had this experience managing our WashU Instagram, Facebook page, etc, like it is there's a lot of layers, but I was also doing it at a time when they didn't really know how to do it. So they were kind of learning with us. I think the institution will flex with time, but obviously it's not as nimble. A large organization is never going to be as nimble as a small outfit regardless of how devoted they are and what kind of lip service you get. I also think though, with time, I think the--because IVF units, they make a lot of money for their hospitals and I think with time as hospital leadership and academic medical center leadership evolve, I think more and more of those new leaders will have personal and at least know people who struggled with infertility and needed IVF and will have an intimate window and they'll be more sensitive to making the unit a priority or at least advocating for more tomorrow than they did today and yesterday.
JONES 14:26
When you mentioned that exercising the autonomy as an individual, that I can start my own Instagram handle, for example, and promote my own personal brand, but is that always possible even if--it sounds like it's been possible for you. I've spoken with others and granted, some of the people that have been in training, but they have had their own social media channels. I don't want to say anything about where they are or who they are, but they did a great job of promoting awareness and educating and it just included their program at a very peripheral level, like maybe they were wearing something that had the insignia of the institution or it was at this setting. And something came down from their boss's boss's boss that said, Stop, delete this immediately. And they're not even sure why, but they've got this mandate to cease and desist from superiors that are further up the chain than they've even met before. And that seems really discouraging for intrapreneurial physicians, for talent, that want to take ownership, that want to educate, that really want to participate, and, in my view, only benefits the program overall. I guess, how often do you see that or what are the implications of that? Because to me, it means Okay, well, I guess I have my answer if I were thinking about continuing with this institution or joining up with someone else in private practice or in a large group, right?
OMURTAG 16:12
I think, again, all the institutes, every setting is different, but you need to also figure, you kind of also need to be wise about things. If you're going to say, Okay, cool. I'm in an academic setting. I know there's medical public affairs or some sort of office, let me find out who that person is. Let me let them know this is what I'm doing. And let me figure out what the ground rules are for the institution. There are going to be some people who are going to meet some resistance and trust me, I have encountered those people, but after you explain after you figure out what are your what are the rules, okay, you want me to fill this form out and make sure if I'm going to include a patient's picture, I just need to write fill out this form. Okay, cool. You know, two years later, oh, I haven't been filling the form out correctly? Okay. How do you want me to fill it out? Okay, you want me to fill it out this way. Okay, done. So incorporating these things. Yeah, it's annoying when some-- in a private practice, I could just say, hey, is it okay? Presumably, you could just say, Hey, can I use this on social? Yes. Okay, cool. I don't need to have this written documentation, perhaps. Some clinics, some larger private clients may require it to have something in writing. So I think--so I've encountered these things, they can be turn-offs, but they can also be opportunities. So for example, if you're in an institution, and you have skills with social media and patient education and engagement on your platform, you should highlight that and promote that and say, Hey, Dean of Education, hey, Dean of Curriculum, hey, department head, and I would honestly focus on the medical school apparatus. That's what we've done here and say, look, this is a tool, we should do a faculty development workshop, I can help lead it and that's how you leverage your skill and it's not so much, Hey, let me build my platform, you won't let me build my brand, or you won't help me build our brand. It's let me teach everybody in the institution how to build our brand and their brand. Because an academic center, they want to know what can you do for the center-at-large? Not so much what can you just do for your slice of the community? Even though that's what you want to do, you leverage the whole institution to get buy-in about what your skill set is, and then you cash out later to get whatever you need to do your divisional thing.
JONES 18:33
Does that contradict that potential benefit of just--well, I mean, you mentioned before--if I just want to build my own personal brand, I can do that. But in this case, I have to sell it back to the--or I can't and then I have to sell it back to the group?
OMURTAG 18:51
I wouldn't say it’s so much I have to--like okay, I want to build the WashU REI division’s Facebook page. Okay, there's some bureaucracy I gotta go through, I figured out what it is. I just have to fill out these forms, I set up the account, they made me an administrator. I’ve just got to use some common sense and recognize that when I post on here, I'm talking about the institution and give me free rein. They're not going to give someone free rein who's just like, I've never done this before I want to do it, they'll probably want to know a little bit more about what your messaging is. And I would have a--if you're a novice to it, then I would say, these are the things I want to talk about, here's the content I want you to post. And here's how I want it. I mean, I'm happy to advise anybody out there on this, because I think this is so important. And I think there's a good path to do it. And there are other paths that can get you shut down, which again, can be discouraging and be a reason why people might not want to deal with it. But I promise you it can actually be very rewarding.
JONES 19:54
Great, because I don't want to advise anyone on that! So if you're looking for a consultant on managing approvals through a university setting, Kenan Omurtag is your consultant and he's expensive, but it's worth it.
OMURTAG 20:09
It's free 99 for the first hour!
JONES 20:12
Can we go through a hypothetical situation?
OMURTAG 20:15
Sure, let's do it.
JONES 20:17
And maybe it's not hypothetical, because maybe you've done it. But I think that every fertility center in North America, possibly the world, should do a baby reunion. I think it's one of the best marketing tools that you can use. And it's also so foundational for every marketing strategy that can come from that. When I consult with practices, usually it comes up early on in strategy sessions. The timing of when we do it might depend on its priority for project, but it doesn't take me too long to convince private practice owners of the value. And it's like, great, all right, well, we're going to pick the venue. We're going to get the food, we're going to get the videographer, and here's what you're going to do, here's the strategy. And it's not terribly difficult to implement. It's logistically involved, but approval wise, it's a thumbs up from the practice owner or the executive director. And that's it. We're doing it. If you wanted to do that within an academic center, what would we need to go through in order to have it become a reality?
OMURTAG 21:29
So we've talked about it here. And actually they did one for, I think the 20 or 25 year reunion here. They did one at the science center, it was a big production. It was, in talking to our division head, he said, you know, it wasn't really that hard to set up. They just told medical public affairs and then the hospital outreach folks and they arranged it for us. That was in 2005, though, how would you arrange it today? It would be very similar. We would reach out to our--so like, I have liaisons that I'm in contact with that I contact and say this is what we want to do. This is what the game plan is. Let's make it happen. And they will ask some questions about it. And then they'll set it up based on what--who they think is going to show up and whatever their experience is in setting things up. So I agree with you. I think these things are--they're very sentimental. They're amazing emotionally on a number of levels. And yeah, I mean, there is a marketing benefit to it as well.
JONES 22:29
Does the Dean need to approve it or does the Dean's office need to approve something or elsewhere in the university? Or they say yes, you can have a reunion, but if you want to have a videographer there, you need to have this approved or if you want to have it at this venue, we need to put out a purchase order to pay for the venue? What else is involved?
OMURTAG 22:53
That's a good question. I think it would vary by institution. So for example, I don't know if the university would have some regulatory things. And this is where it can get frustrating. The university might have some regulatory things, or the hospital might have some regulatory things. It's just variable and I think it just depends on the institution. I think in some places, it'll be more seamless than others. I think it always comes down to who's paying for this is always kind of, like whoever's paying for it is ultimately going to be the one that gets to decide what the process is, whether it's the hospital or the academic center, and that can vary. The Dean may not care, the Chairman may not care. It might be a solely divisional process that's led and paid for. It might be the division that drives it and the hospital pays for it. It is so variable. But you're right, if you're in a private practice, there's fewer layers of bureaucracy that are there. So you can just say, yeah, we're doing this, this is what we're doing, we're paying for it and let's make it happen. I mean, that's the thing when you're in the academic center a lot of things are not coming necessarily out of the division pocket, they might be coming out of other people's pockets. And that's what leads to the bureaucracy.
JONES 24:08
I'm emphasizing these cons or exploring these cons because I'm an entrepreneur. I have a tilt to a certain way, which is I want to have the control and not have the--that isn't important to everyone. I think it is important for entrepreneurial and some intrapreneurial docs to consider. But let's talk about some of the pros as well, because you outline them, but let's talk about the the passions that you have for the Academic Center, that if you're speaking to a certain profile of a physician that's entering the workforce, you would really want them to consider what the academic IVF center has to offer that might be less common in private practice.
OMURTAG 25:00
I mean, it kind of comes down to really two principles. And that's, for me, at least, it’s variety and opportunity. And when I say opportunity, it's opportunity for leadership. So you have--in an academic medical center, you have a lot of variety. If you wanted to just grind out and see as many patients as you can, do as many cycles as you can, and that way you can get your experience quickly, there's an academic center for you that can help you achieve that. Because trust me, they want you to see patients as badly as anybody else. Because, as they say, no margin, no mission. You have to see a lot of patients in order to generate the revenue to help support the other missions of the institution. So clinical care and the revenue that's generated is very important. And there's that, but you can also have other variety so that you don't get burned out so quickly. Because you can be out here and within two years see 5,000 patients, and then you're like, okay, I'm like totally burned out. I need to explore something else. That might require you to either leave your current situation or try to find something within your current situation that allows you to have variety. And many people often find it, but the academic center provides you more structured opportunities for education and research that may not be as prevalent anywhere, or at least have the infrastructure or the depth that some people want to explore.
JONES 26:38
So what do you mean by opportunity for leadership? What exists in the university setting that is a track for leadership that one wouldn't necessarily find in private practice or a fertility network?
OMURTAG 26:53
Well, if you want--so I mean, just kind of starting,if you want to start at the top--if you aspire to be a administrator In a big academic center like a Dean, a Chairman, I mean, take it even all the way up to a Provost or Chancellor, you got to spend a lot of time bouncing around or staying in one academic institution and gathering a lot of experiences over time. That's not to say you couldn't do those things if you were in private practice and came back. But if you want to be a--I wouldn't say necessarily a Residency Program Director--but if you want to be in hospital administration, if you want to be a Chief Medical Officer, if you want to be a Vice President of Clinical Affairs for an OB/GYN department, because you really know how to see patients very efficiently, you know how to implement an electronic medical record, you know how to engage patients with social media. You can have a bigger impact on the institution at large and the community at large if that is your desire. Now, obviously, if you're just, you're like, you know--I'm seven years out these things were always on my personal radar, but my first five year goal was I'm going to be the best reproductive endocrinology and infertility specialist I can, reevaluate with the next five years will be at that point. Here we are, we’re at the next five years. I'm going to push myself to be the most efficient reproductive endocrinologist and fertility specialist and learn how to incorporate an electronic medical record and social media engagement in my daily routine. And I'm going to try to be the best at that. And I'm also going to advocate for those skill sets within the institution to at least promote the possibility that, hey, this is the future of medicine, I might have a skill set that could be valuable to our division, department and institution at large. So can you come over here and listen to what I have to say?
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JONES 30:42
I see that leadership track as something that I--there's definitely a profile of doctors that that’s what they're interested in. I don't think that it's--that type of track exists in parallel with or exists at the same level at a fertility network, let's say. But one benefit that we haven't talked about is the case, I think that had been made for a long time, which is, there's less to worry about that is not related to medicine in the academic center. Meaning you don't have to worry about payroll, you don't have to worry about choosing the HR company, you don't have to necessarily worry about marketing. Whereas if you're a single physician, practice owner or even a partner in a two to four or five group, you do have to worry about those things. And that was very often considered a large benefit. I wonder, are we talking about that less, because there's a third group now? It's no longer a dichotomy between the academy and private practice, but I break private practice almost into two groups entirely, which is the independently-owned, let’s say 1 to however many docs, and then fertility networks, multiple groups, multiple doctors, multiple labs and multiple states, sometimes multiple countries. And now, that might be something that they can offer, the fertility networks can offer, that the academic institutions still offer, but used to have as one of their cardinal selling points. I can go work for this larger group and I don't have to worry about payroll, I don't have to worry about HR. There's a CEO, Chief Human Resources officer, they've got the C suite and the processes in place. Does this new rise of the fertility network disrupt the recruitment appeal of the academic center in any way?
OMURTAG 32:41
I think it does, but also I don't think it really--I mean, I think it does, just in the sense that you have more job opportunities as a result of the business model. But I agree with you. The “I don't have to deal with payroll, I don't have to deal with my malpractice, I don't have to deal with all these ancillary things,” I think most people are not really interested in doing that any place. And that had been academia’s calling card, you're right. Now that there's this kind of third party or third method, but this has kind of been around for a while now. And a lot of physicians are getting used to--like I came up of an age where, you know, physicians were, it’s kind of like, okay, yeah, cool. I'm an employee. The idea that I would just be under these shingles by myself and setting up the whole thing was something I saw with my own uncle who struggled with that transition. So to me, it was never--I mean, I always viewed my job as being an employee. Now, what I will say though, is the fertility networks may provide new opportunities for leadership over time, not immediately, but there may be new opportunities on the leadership side that had largely been and still are traditionally held by academia. One of the other things that academic centers, you know, talking about a pro, the fertility network will provide you your fringe benefits and all these other things and make it pretty easy for you to just plug and play. But the academic centers, specifically the private academic centers, usually have fringe benefits that are very valuable to a lot of people and the biggest one is a tuition benefit. So for here at WashU, for example, if you've been an employee for seven years, you'll get a tuition benefit, so that your children can go to WashU for free, or they can go somewhere else with 40% towards the cost of that tuition. And that's a big deal. But you could argue, I could go work in private practice, make more money and make that up pretty quickly. So it's, again, you can kind of go back and forth on that pro and con.
JONES 34:53
I want to go back to convergence because we're talking about fertility networks as one path as academics is another, it seems that they may be coming closer and interweaving in ways that we weren't seeing 10 or 15 years ago. You know, we see certain university systems that their division is owned by a private equity firm or partly owned or they're part of a fertility network. We see private practice groups that have fellowships in concert with large university systems and so-- I'm not too familiar with this area, maybe you can help shed some light on it, but is it possible for any REI division to be sold to a private equity firm or can Fertility Bridge come in with some private equity money and broker a deal with Washington University and say, Okay, now we've got 40% of it and so it is private, but it's also through the university. How does that work and what's the trend that’s happening if there is one?
OMURTAG 36:00
Yeah, I mean, just purely hypothetical, right? Like, I mean, the example you gave just for the record, purely hypothetical.
JONES 36:09
Yes. I do not have millions of dollars in Wall Street money yet, unless the right private equity firm is listening!
OMURTAG 36:17
To your point earlier, yes, we are not trying, we are not scheming something. This is purely hypothetical! No, I mean, seriously, though, again, it comes down to all politics is local, right? I would encourage anyone who's interested in the relationship between Chapel Hill and UNC Fertility Clinic and Integramed, to talk to Mark Fritz and he's told his story about how that relationship came about. I think it really just depends on does the institutional leadership feel like a third party, be it you know, private equity firm or just a practice management firm or whatever--is it better equipped to do the day-to-day operation or satisfy the needs of the division and its clinical services and or its other services for that matter, more efficiently than the current infrastructure? And I mean, I think many times the answer is probably, but it's so different from institution to institution that there might be a financial disincentive in the long term, there might be financial incentives up front that may not be good in the long term. So I think these contracts and these relationships have to be dissected individually. My guess is it always comes back to you know, what's in the best interest of the institution? You know, if the REI division is going to fold, if this doesn't happen, that's a big problem for the department. That's a big problem for the residency program. It's a big problem for the hospital. It's gone down the line, so then it becomes an issue. If it's more we think we can do this better, we think maybe we can make an extra $250k a year based on this and profit wise, maybe the administration is like, yeah, let's do it. Because whatever the negatives are, are outweighed by that benefit. So it's just a cost benefit analysis that each institution has to do based on the relationship and the negotiation between the two parties.
JONES 38:20
Maybe this is a question for Dr. Fritz or others in similar situations, but does that change the financial relationship or potential for employment agreements or what's in employment agreements between the physician and the system? If, for example, are there partnership opportunities? Can you be an equity owning partner, a shareholder in that institution? So now that you're--does that happen?
OMURTAG 38:50
I'm sure it does. But I'm curious who gets to be a partner? Maybe not everybody, maybe certain people do. Maybe only one person. Maybe the most senior person who drove the whole project is the one that gets to benefit the most. Maybe a small cadre of people. Maybe everybody does! Maybe everyone is now, you know, university employees, but the hospital runs the whole operation and is responsible for the entire operation and the university is nothing but a symbolic thing and oh, all the physicians keep their University benefits. But the entire project is run and operated by either the hospital, some third party, and they collect all the money, and then they just push it to the University. These relationships can get very complex quickly, because of all the different parties involved, especially in large academic medical centers where you're usually dealing with the university system, the hospital system, and then whatever this third party is. You know, like many places those systems are aligned. Might take partners in Boston, the Harvard Medical System, you know, Harvard Medical School has three partner hospitals and together they are all called partners. But, you know, in a lot of systems, those two entities are wholly separate and they're aligned, largely aligned, but they still have different pieces--they're different components, like our IVF lab is owned and operated by the hospital, but if you walk through a different room, the laboratory that does semen analysis and runs all the bloods is owned and operated by the university.
JONES 40:35
We have, we have a few guests this year that might be able to share some insight on their experience. And, and I'm going to look for a few more because you've raised some more questions that I'm really interested in and this convergence and divergence of private equity of the of private care and now the university and the health system in a way that I just--this wasn't happening 10 years ago, was it?
OMURTAG 41:06
It was happening in 2005. I could go back even further. There's a good article--let me tell you this. There's a good article--this, what we're talking about today, as far as kind of the limitations of or kind of like, what is it like practicing our infertility care in an academic center--was talked about by Michael Soules in Fertility and Sterility, Richard Reindollar, Richard Paulson in a 2005 issue dedicated to this question of what is the future of the academic REI practice? At the time, a prominent, I don't really know, Dr. Soules I think he was at University of Washington--and I apologize if I'm getting this incorrectly--but he writes in his article, and I would encourage anyone who's interested in this topic to read this article, he wrote an editorial about talking about the challenge she was facing in the university about promoting his clinical mission and all the bureaucratic layers and everything. And then everyone kind of wrote their own editorials kind of in response. So check out that Fertility and Sterility issue because it shines a light, the same conversation they're having 15 years ago is kind of what is being had today.
JONES 42:21
Okay, so it has been happening for longer than I had considered. If we're seeing more of it now, it means that there's different types of career paths for people that are going into--whether they're going into a fertility network or private practice or through a university system, there's more. I want to talk about some of the traditional ways that employment agreements are structured or compensation is structured in academic centers. Can we talk about that?
OMURTAG 42:53
Yeah.
JONES 42:54
So are most academic systems is there--are most of them RVU based? Or are they all RVU-based--relative value unit for those that might not use that?
OMURTAG 43:08
Yeah, many of them are. So I get, based on my RVUs I get--we are salaried employees and I get bonus based on clinical production and academic production. So a lot of institutions that will do this thing where they'll have academic RVUs, where you'll get certain points for publishing, teaching, being on a board for something, being on a committee, etc. And then they'll also give you clinical bonuses based on your production that are RVU based. So your base salary can, you know, if the base salary for someone coming out of fellowship is $250 in the academic center, you could get, depending on the structure of the institution, your clinical bonus if you're very pretty productive could get you well into $300 and above, depending on region and all this other stuff.
JONES 44:06
So if I understand correctly RVUs are typically broken up into work RVUs, which is what we're talking about here. It's mostly what we're talking about when we're talking about RVUs. There's also practice expense RVUs and malpractice expense RVUs. Is academic RVUs and clinical RVUs, is that to say that there's four as opposed to three and each of those two are sort of fill in for work RVUs? Or are clinical RVUs, work RVUs, and academic RVUs, something separate?
OMURTAG 44:44
The latter. Clinical and work RVUs are the same. And then academic is you know, proprietary.
JONES 44:52
Got it. And so how are academic RVUs measured? Is that by courseload, or--
OMURTAG 44:59
Point scale.
JONES 45:00
Can that be labs, courses, if you’re the attending for a certain group of physicians--how does that point scale work?
OMURTAG 45:08
Let me give you some examples. I wrote a, I'm the first author on a paper, I get five points. I'm a co-author, I get two points. I gave a lecture about primary amenorrhea, I get two points. I run a course for the medical students and coordinate 23 hours of whatever content and have to deal with faculty and their schedules, I get 20 points. Those are some examples. I am a board examiner, I get 10 points. And I mean, this is random. But you can see there's like some sort of scaling as to, you know, if you just go give a 30 minute lecture, that's less points than if you spend time managing or you’re the editor-in-chief of a journal, that's 20 points. Oh, you got an RO1 Grant? 50 points. So there's a scale that then everyone's academic RVUs are tallied. And this is again, there's a lot of variety on how this can be done. But people are like, Okay, you got this. So based on the profit for the division or the department or the school, however it's laid out, here's the algorithm that, you know, based on this is how much we have per RVU based on how much total profit, it's so distributed accordingly.
JONES 46:24
Okay, that makes sense to me. I've seen other systems use what is called--I've seen it called forgiven time or protected time, where let's say a physician has an RVU target and then the institutions say, Okay, but this percentage of time is protected. So that means that they only have to generate--you know, if 10% of the time is protected, they only need to generate 90% of their RVU target or if it were 25 percent and they only have to reach 75%, is that in lieu of having academic RVUs?
OMURTAG 47:06
No, that would be in addition. So, like, a common scenario in an academic center is like, for example, the medical school will pay 15% of my salary. They'll pay for 15% of my time. Because I educate--I spend time educating the medical students. So in order to get the quality that they want, they have to buy my time. So not only are they supporting my salary--I'm not getting additional money, but my department just has to pay me less because the rest of what they're supposed to pay me for my base is coming from the medical school--coming from another revenue stream.
JONES 47:54
Okay, yep.
OMURTAG 47:55
But that's how--that's how it works. But I still, on top of that, you know, charge academic RVU time. So I say, hey, look, I'm doing this, I'm still doing this, I'm still doing that. And I'm still seeing all these patients too. So you can generate, depending on the structure, you can fight for kind of your time like, hey, look, I spent all this I spent six hours a week managing a social media account for the division. Maybe it makes sense for me to ask the department to pay for 10% of that time, because I'm going to also manage the entire department’s social media account. You want to do it right, you’ve got to pay me for that time. Oh, we don't think it's important to be paying this person. Okay, fine. Well, then, you know, I'm going to--you don't have a category for it in the academic RVU, make one or I'm just going to put it as 20 points, which is what I did.
JONES 48:43
Yeah. So does it typically happen when there isn't a category in the academic RVU? Is that typically when time is bought back?
OMURTAG 48:52
Well, the nice thing is most of the--again, I'm only speaking from my experience, you can just fill in what you think you deserve and they can decide if they think it's worth it. If this is worth giving, like, obviously I'm not going to say, Hey, you know, I drew this picture of how IVF works, 4000 points you know,? Like I'll probably say five points. I made a video, I put it up on the web, it took me some time, so it’s five points. I tried to calculate how much a point is worth, but I wasn't able to get to that, but it was actually worth a couple hundred bucks. So, I think the scale actually works nicely.
JONES 49:35
Who does calculate the points and then who calculates, this is this service is this many RVUs and then who calculates the compensation for that?
OMURTAG 49:45
The department management does that and it's subject to change depending on the profit of the entire department. Is typically how--
JONES 49:55
Do they vary widely from university to university? If we’re at Stanford, would we expect to see something very different at the University of Iowa or in Florida? Or do they tend to do--is a retrieval generally this many RVUs and a transfer is this many? Are they similar?
OMURTAG 50:17
So for those CPT--yeah, they should actually be the same as far as what the RVU multiplier is. As far as I know, I'm not gonna pretend like I'm an expert in this. RVU multiplier for the procedure should be the same largely, although I don't know if the multiplier changes by region, or if the dollar amount changes by region. There's probably some calculation of that--
JONES 50:43
I believe it's the latter but I would love for anyone that's listening to correct me if I’m wrong and they'd like to speak on that. I think that's very useful. How many academic RVUs and how many clinical RVUs can a new doctor let's say it's a doctor that's maybe in their first or second year of employment, expect to produce each year each day?
OMURTAG 51:07
How many academic ones?
JONES 51:10
Yeah, so how many academics and how many clinical?
OMURTAG 51:14
Okay, so well the work RVU is obviously just a function--again, like, hey, we're going to start you with four patients and you're like, no, I can see five, that will help drive your downstream work RVUs because if you see that extra patient a day, or a week or two to three a week, those are going to generate more opportunities for a procedure, which is going to generate an RVU and again, depending on--or an ultrasound, which is going to generate a clinical, you know, work RVU--again, all of these are wholly dependent on the local fee structure and how things work. But if you want to boost your work RVUs, you just see more patients, and you figure out a way to work it in.
JONES 52:03
So are the targets set? You know, let's say if like, I don't know, let's say the average doctor’s expected to produce 9000 RVUs a year and then maybe you take out 100 weekend days and maybe you take out 65 vacation, sick days, etc. Maybe you've got into--you're dividing 9000 by 200. I guess. I don't know what that number that would substitute for 9000 actually is or if you have 45 work RVUs as your target per day, how that is balanced with academic RVUs?
OMURTAG 52:46
Well, I think it's--you’ve got to figure out, Okay, what is probably the most value. Like what am I going to get? if your work RVUs are dictating your salary and/or your bonus more so than your academic ones, you're going to focus on how can I maximize my work RVUs?
JONES 53:10
So are you saying that that target is constructed by the individual? They can say I want to spend more, I want to have a higher clinical RVU target than an academic target? Or is it set by the department? They say this is your target for academic and--
OMURTAG 53:27
You know, I'll tell you, it is variable. All I can really speak to my experience which has been, you know, usually the clinic will tell you, these are how many days of clinic a week you're supposed to be doing. So they may not have a work RVU target. They might say you need to be in the clinic, four days out of five, seeing patients eight to four, and then you can have this fifth day off as an administrative day to do whatever it is you want to do. Like, some of these contracts from the academic center might say, your contract is for four half days a week and then you can kind of do whatever. That's all the contract says. There might not be an RVU target in that contract, which is crazy. It’s not in the contract, but someone will tell you, hey, you're not seeing enough patients and you can be like, but I thought you said I just needed to do four half days a week?
JONES 54:36
Well, this is one of things--I often criticize employment agreements in private practices that, particularly with eligibility for partnership, eligibility for buy-in, it's not enumerated very often in employment agreements. And so I thought, Well, certainly systems that use RVUs would have that enumerated, but you’re saying that’s not always the case where targets are enumerated.
OMURTAG 55:02
No. I mean, no one has said--I mean, I get monthly updates as to where my targets are and how I'm doing and I usually compare it. And I'll tell you the first year I was like, What the hell is this? I don't know what this is? Can someone explain it? I mean, I conceptually know what it is, but I don't know what it is, honestly, let's be real. So then I kind of said, Okay, I did this amount. So I guess, okay, this amount of RVUs led to, and academic RVUs led to this bonus plus my base. Okay, that was my target. Alright, cool. So maybe I should stick with that or maybe cool, I wasn't that busy, there was some other stuff. Let me push it next year and let me change the schedule. So I have some autonomy in my current setting to kind of set A) let's do a little bit more here or let's kind of back down a little bit on this side with obviously a sign off from leadership.
JONES 56:04
Well, you taught me a lot more than I knew about that subject. And hopefully for the listening audience as well, especially those that are mapping out their career path within the next few years. I'd like to conclude with just how you see the future of the Academic Center and the participation of entrepreneurial physicians because I very much include you in that group. You and I met at my very first meeting in the field. So a lot of people don't know this about me, but I had moved back to the United States in 2015. And I didn't know anyone at that time. I went to MRS, which was the Midwest Reproductive Symposium, a meeting that I was unfamiliar with at the time. You were speaking. We started talking because your topic was about social media. And that's how I broke into the field was originally just through Facebook community management, which grew into social media, which grew into digital marketing. And a lot of people are familiar with my book, The Ultimate Guide to Fertility Marketing, because it's what they download. But there was actually a book before that. I don't even know if I still have a copy of it digitally anywhere! It was called Digital Marketing for Fertility Centers.
OMURTAG 57: 23
I remember that!
JONES 57:25
In which you were a contributor, and your name is on that as well. And so I think you may have been the very first person that I ever collaborated with someone on content within the field. Then we didn't talk for three and a half years and now you're back on the show, but I do consider you one of these people that's very intrapreneurial. And so I'd like your thoughts on including of how that intrapreneurial profile, someone who wants to add to the system, not just say I'm already following an established process, but rather contribute to it. What's the future for them and consequently, for the Academic Fertility Center REI Division?
OMURTAG 58:14
Wow. I mean, I appreciate the shine, man. I mean, I'll just say real quick. I remember after the talk I gave in Chicago, you were like, Hey, man, you should maybe think about this Instagram thing. And I was like, is that what people take pictures of their food and stuff? And you're like, Yeah, and I was like, What about Twitter? And you were like, Nah, man, that moves too fast. You should check out Instagram. And I came back to Instagram like two years later and I'm like, yeah, Griff was right. This is where the action is. This is the best platform for this. So shout out to you man and what you've been doing with Fertility Bridge. I do also remember reading some other blog of yours about and it probably was on Fertility Bridge, just about the future of the field. I mean, I think your insights are pretty accurate and kind of the way I see it is pretty, like--what I read from you is like, I'm like, yeah, that's pretty spot on. So anything I can do to inform the academic side, and really the field in general to add to your knowledge and your community, happy to do! So as it relates to the future, I don't think I'm the first person to say this, I know I'm definitely not, but I think the future is going to be for the field in general, is going to be about consolidating and using IVF as a treatment tool and a prevention tool for disease. I think we'll see more of that. And I think that will be regional at first, but I think over time, that will become more widespread, given the ability to test embryos and the potential use of CRISPR. While terrifying for a lot of folks, maybe inevitable for others. I think that's something we'll be dealing with in our lifetime, for better for worse. But from the academic--I think the other thing to point out is what is the role of the academic medical center in medicine specifically in reproductive care? Because a lot of the innovation, and a lot of the tinkering in science usually comes out of the academic centers and then gets pushed into practice. That's not--like in our field, that doesn't really happen that much anymore. I think ICSI was probably the last thing that came out of a purely academic pursuit. I mean, there might be other things I'm missing, but I think the biggest role the Academic Center has to play in pushing forward the progress of Fertility Care is in its ability to provide access to Fertility Care. Academic institutions are large. They have 15-40,000 employees. State institutions are big. Times are changing. And employees want a fertility treatment benefit, who better to give it than their employers. And I think fertility clinics and reproductive endocrinology divisions have an opportunity to lobby university and hospital administrators to make carve outs for institutional employees that are exclusive to the institution’s fertility practice. I think that will be the future of the academic medical center and how I can leave its best imprint on the reproductive endocrinology and infertility division and its surrounding community.
JONES 1:01:27
All capital letters. Dr. Kenan Omurtag, thank you for your kind words. Thank you for your contribution to the content over the years. And thank you for the insight that you gave us today on the show.
OMURTAG 1:01:39
Yeah, thanks for having me, man.
***
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.
