Listen on Google Play / Apple Podcasts / Spotify
Privately-owned, private equity-backed, academic medicine, independent practice...each type of clinic comes with its own set of pros and cons, but are all of them going to be around forever? On this episode of Inside Reproductive Health, Griffin talks to Dr. John Nichols. Dr. Nichols left his job in academic medicine to open his own private-practice, Piedmont Reproductive Endocrinology Group (PREG) in Greenville, South Carolina. They discuss Dr. Nichols’ journey, his thoughts on the benefits of independent practices, and whether or not these clinics will continue to be relevant in the ever-changing fertility world.
Learn more about Dr. Nichols and his team here or visit www.PREGonline.com
To get started on a marketing plan for your company, complete the Goal and Competitive Diagnostic at FertilityBridge.com.
Other episodes mentioned in Episode 52:
Ep. 50 with Dr. Pietro Bortoletto
Ep. 9 with Holly Hutchison
Read Griffin’s blog post about REIs leaving their practices on our blog.
***
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
Today on Inside Reproductive Health, I'm joined by Dr. John Nichols. Dr. John Nichols is a fertility specialist from Greenville, South Carolina where he has been in the field for over 20 years now, having been a part of the delivery of several thousand babies. Dr. Nichols is a double board certified OB/GYN and REI. He spent his first six years on the academic side of things. In 2003, he left to form Piedmont Reproductive Endocrinology Group, sometimes known as PRAG, which is in Greenville and now is the largest REI practice in South Carolina. He's done that by expanding the practice to five physicians across four offices. He's been named among the Best Doctors in America as well as the Best Obstetrician and Gynecologist in America. Now, I didn't have a plural on that, John, was that singular? Were you named the Best Obstetrician and Gynecologist in America?
DR. JOHN NICHOLS
There’s a plural there!
JONES
Among the plural! And his recent work with intravaginal devices for IVF has allowed many infertile couples in the Carolinas an alternate and affordable option for fertility treatments. We're going to talk about that and some other innovations happening in independent practice. Dr. Nichols, John, welcome to Inside Reproductive Health.
NICHOLS
Thank you, Griffin, enjoyed many of your other podcasts before and so certainly honored to be a guest here.
JONES
I can tell from the writing in places--in the correspondence that we've had and the very brief conversation that we've had and also, it throughout your website that you're proud to be in private practice. And one, I want to see if that assumption is correct, but being at the head of independent practice, I think it's something that your organization seems to be very proud of. And let's start with why that's important.
NICHOLS
Well, I think as a physician, and being able to, in my case, move out of academics, so--I enjoy it a lot, enjoy it greatly. But the difficulty of working in that environment with either university or hospital was hard, especially for the REI-type practices, I get it how it works for surgery and internal medicine and all that, with what we do and sort of the type of patients we deal with and the nuances of what we do, it just, I think, it's very difficult to learn that in university or hospital setting. And I think that's pretty clear across the country, that you find very few big REI centers that are set up in universities anymore. And if they are, they're almost always run very independently. So I was clear in my mind after spending time in academics and realizing the cumbersomeness of the system--you're busy, you're working, we need to hire a new nurse or we need to hire several nurses or we need a new ultrasound and oh, wait a minute, well, that's got to go on the capital budget, we need to have a meeting, that meeting’s not for another three months, you know, we'll get to it. And I'm like, no, you don't get it! These patients are paying money, we're generating revenue, this doesn't work. So those kinds of things make it very difficult. And so I think that's a lot of reasons why you see independent REIs away from university settings, and clearly that was something I wanted to do. And plus, at the end of the day, you know, I could see myself working at a university for 20 years, 25 years, getting ready to retire, you know, you get a good, nice little party, a clap on the back and a gold watch and a thank you for your time. And that really, for me, wasn't what I wanted. I felt like, listen, I think I have the ability, and with good help, to set up and build a practice, build something that we can grow and develop and build a bit of a legacy and turn those over two to the younger doctors who come in and want that same kind of mindset--build something; grow it; we run it; we take care of it; we decide how we want to make this work; we need new things, we get it; we need a new nurse, we get. And the whole premise behind this is that that's just the best way to take care of the patient. At the end of the day, these patients are paying money, they're spending a lot of time and effort, we're putting into lots of stuff. And if you cannot really do all the things to take care of the patient appropriately, I think that's very hard. And I found that very difficult in the hospital when the patient would come to me and say, “You know, Dr. Nichols, I love you, you’re doing a great job, but I can't deal with the office. I can't deal with your billing people. I got to go elsewhere.” And that was heartbreaking for me and I felt bad for the patient that they had to go travel elsewhere to get the kind of care that needed to be done. So those are all very basic reasons, but I think important reasons why moving into an independent practice and doing that and with a mindset of the group to do that forward is really honestly about taking good care of the patient. And if there's a problem, we take care of the patient. She has a bad outcome for some reason that we had some control or didn't even have control, we could decide if we wanted to do something for the patient to help them as they move forward. Those are things are very difficult to do in a big system.
JONES
We talk about those dynamics in the academy in another episode with Pietro Bortoletto. And having had some interaction, but really just--we've only done some work with centers that are in universities and larger health systems because there's so much red tape even for really basic programs or really basic consulting help. Now we see a whole other category. So I would say that's the old dichotomy--if you had practices within universities, in large health systems, and you had independent practices, now there's a third category, which I would say is still private practice, you could say, but not independently-owned, but rather operated within large fertility networks that have at least part of their equity sold to private equity firms--coming from private equity firms. You're not in that category. You are among a, now, smaller group that is still within that independent segment. And I know some people aren't getting the offers that others are. But I--just from looking at the optics of your outfit: four offices, five docs, biggest practice in a growing state, I know you're getting phone calls.
NICHOLS
Yes.
JONES
I know you're getting people knocking on your door. Why haven't you gone down that route yet?
NICHOLS
Well, listen, when we first became sort of a presence, a big enough practice that we were getting some motion, people were hearing about us--and you know, I was approached by several of these already. Integramed, that really was kind of the first, as you’re aware. They were sort of the first to come into the fertility field and set up these networks. And there were several practices in my area not that far away that are Integramed practices. And I know the people there and they were like, “Oh, John, you’ve got to join this network! Come on. We want you to be involved!” And I was like, “Show me the numbers. Show me where this makes sense to me. Because I'm not quite sure I understand why I need somebody to manage me. We're managing our stuff very well. I have a great office staff, great office manager, we're doing all the things we need to do. And we don't have to outsource, you just have to hire good people and competent people and take care of those people.” That's probably the most important thing. And when they came and showed me the numbers I just said, “Listen, I'm basically going to be paying you a lot more than what I already pay my people to do now, and I don't see the benefit of it.” And so from the start, all is sort of left a bad taste in my mouth about how this would work. And then as I see more and more of these other VC groups coming in and buying out and, of course, I hear from these docs that have been in the systems and I'm hearing what's happening. Yeah, it may look good up front to get a cash prize, so to speak, but at the end of the day, coming back in and being an employee, and then having somebody else that's outside running it. This is a business, don't get me wrong, but it's not the same kind of business if you're running a car lot or you're running, you know, some other type of service business. Our business is predicated on once again, taking care of patients. And if you can't do that, well they say, well, you have great nurses or you have great embryologists, and you want to compensate them for that or bonus them for that, and when you have corporate saying, “Well, no, we don't do that. Or no, this is a pay cap. In fact, we have to drop their pay down because that's more than what we expect to pay.” And so those kinds of things really limit what you can do to take care of your employees and make them happy and at the end of the day, that's all about how you take care of the practice and the patient. Because when they're happy, they do a good job, you're compensated, they know that you're into them, they know that you’re bought in, and they become vested, and that's how you run a practice. When people are vested, and people have the, you know, go the extra mile, hour, extra phone call, whatever it is, to really take care of the patient. And that's not going to happen in those things. It just, it just can't. It's not part of that system in practice. So that's the biggest reason why we stayed away from it. It just doesn't work for our model.
JONES
So those things that you mentioned, hiring people, investing in management, helping them to build the structures--that can be a full time job in and of itself, especially as a practice starts to grow. And this has been a recurring theme on the show that I talk about with guests. How is that independent model able to keep up when the person who should be in the visionary seat of thinking of future value, of having core relationships with the strategic partners, with maintaining the culture of the practice, is also in the integrator seat of being the Chief Operator, holding management accountable, and implementing the process coming from the visionary and also being in the REI seat of seeing however many hundred patients per year and doing 200 retrievals a year--how is that model, or someone who's at the head of that model, able to compete with the speed of an organization where the corporate side is here, you've got the Chief Executive Officer in the visionary seat, you got a Chief Operating Officer in the integrator seat, you’ve got the Chief Revenue Officer in charge of marketing, Operations Director in charge of ops, or maybe you have a Lab Ops Director, Clinic Ops Director and Office Ops Director depending on how you split it up, you've got Chief Human Resources officer, a CFO, maybe even in-house legal counsel. How can the independent practice compete with the speed that that structure provides? The person at the top has to do it all?
NICHOLS
Yeah, well, I think, well, number one, there's no way that first top can do it all. In fact, there's no there's no way I did any of this without the help of very good competent people who bought into the same vision that I had. And so there's no doubt in order to lead a good organization, you have to have good people with you, that are working with you, and seeing your vision. But not only that--and I think this is the important piece that I've found out--is so much about having employees and office managers, a CFO and an office manager in each of the different offices we have, and all the staff, whether it's lab, whether it's nursing staff, you know, people who head over each one of those divisions--it's really allowing those people to take their job and embrace their job and move forward with that job, become leaders in that job, where they didn't have those opportunities before. And I think when you when you help build leaders, and that's what it's about, you're building leaders in each one of your groups that allow them to take the reign and run with it under, you know, your vision and your guidance. And everybody buying into this really makes a big difference because, once again, that's where people become vested, that's where your employees do that and that's the way we've been able to do it. And every office is run the same way. We all have the same mentality about how we run the practice and take care of patients, but everybody's--we're trying to give them new jobs, new opportunities that they grow and expand that they become a better office manager, a better nurse, a better nurse manager, you know, get involved! Like my office manager, she came from a plastic surgery office and started with me, so she had already some basic medical running practice knowledge. And then as she came in--and this is a whole different world that we're in--she got very involved with the ASRM management division. They have a whole nother specialty division, they call it Association of Reproductive Managers. In fact, became the President of that group during her time that she's been with it. So it's sort of like fostering this ability for our employees to move forward and then gain the experiences and gain knowledge and then have that ability and they feel that vision and they get their fulfillment in their own life about how they do things in the business, if that makes some sense.
JONES
It does make a lot of sense to me, and thankfully to you, when I look at other practices, similarly sized to yours though, I don't see the same structure because what you're talking about is certainly investment to have a different office manager for the different locations, possibly have a business manager, and a CFO. And you mentioned, these are different roles and they're different people in these roles. So the more you add and the more autonomy and skill set that they come with, the higher that price tag goes. What I see in a lot of practices similarly sized to yours is one practice manager for all of those! So talk about why you decided to make that investment and why you see the value in those being different roles as opposed to piling everything in the lap of one practice manager.
NICHOLS
Well, I mean, I think, again, employee appreciation is also knowing if they're working hard, you're not working them to death. And so we've always felt that it was important that we know--that we look at our overhead and what we have for nursing and what we have for administration is probably going to be higher than a similar practice. I don't disagree with that. But what I do know, that allows us, still, to continue to grow and build and that kind of mentality that employees know you're looking out after, you're not just beating them to death, working them to death, and we're doing all the things we can to allow them to grow and foster as well, because that helps the practice move forward. Because the practice--it doesn't matter how many employees you have a lot or a little, if you're not busy, it doesn't matter! And where you become busy and where you become successful is when patients come back and say, What a great practice! I'm referring my friends. We build and grow. And the OBs, say--when they go to their OBs after, Oh, that was such a great experience! and referrals keep coming in. And so a practice can only grow if you can let it grow and get patients into the door, which has been what we've done. There's no way we've expanded to four offices without growing and that's where that growth comes from.
**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
Let's talk about the investment in the continued professional development of those team members as well. You mentioned your CFO, Faith, a shout out to Faith for being the Chair of the Association of Reproductive Managers Group, I'm also a member of that group and I invite people to our annual meeting and I invite people to our programming at ASRM and sometimes, I hear of the practice managers of smaller independently-owned practices that, Well, a lot of that applies to the larger fertility networks and not to us. And I don't think that’s true. I think that it's even more important for smaller practice managers to go to meetings like this because they don't have a lot of corporate resources. And so just by having those relationships and that education once or twice a year, I think is really valuable. So I don't agree with it, but I hear it. And part of the reason is because we have more members from larger network groups, partly because they have larger staffs, but partly because that’s who is investing in the professional development of their teams. There's a lot of smaller practices that think, I don't want to pay for my practice manager to go away for two days and I'm going to have them out of the office for two days, and the hotel, and the airfare, forget it. And so you've made a value judgment, apparently, that professional development in the staff is important. Talk about that.
NICHOLS
No, I completely agree with that statement. Because it's been the same way when I look at when I've transitioned through my training. And part of that was all the same thing--I always had mentors ahead of me that that helped move me along, help focus me on things, helped me get involved in the things that I wouldn't have normally got involved with. And I think there's where you learn to become, hopefully, a good leader--and that hopefully translates in becoming a good physician as well. And so we've always taken that approach with our employees to really allow them to branch out, to improve gain knowledge, and gain experiences, and they become better and at the end of the day, that's better for your practice. Everybody gains from that. So we'll spend the extra money to send our nurses, our embryologists, our office managers, different office managers in the office, to go to ASRM so they get that experience because, you know, that's a great meeting! You've been there. It’s a great way to network. And it's a great way, also to say, Wow, look at all these other practices, look what they're doing, what can we learn from them, what can we take home. It helps us. So all of that--and I think ASRM does a really, actually a pretty good job of trying to focus that kind of thing with all the different special groups they have because we have a lot of knowledge to share here and I think it's a great opportunity. And once again, employees go away, they get a great little time in a meeting and there's a lot of social stuff and fun things to do as well and they come back, they're fired up, they're ready to go. And that's the kind of employee I want.
JONES
And it's the networking value that I often see as being the most valuable. So in other words, there's programming there that you can take a couple nuggets away from, that might really be helpful in that moment and sometimes that's the case. But if team members are given the opportunity to build some relationships, I found that the greatest value is from those three or four phone calls that you can make over the course of the year, because you made those relationships, that when you're having that issue--I remember so and so talking about this, or I've become good friends with this manager or this physician or this team member, on the other side of the country, and I want to use them as a soundboard. I just think that's an invaluable resource for smaller practices to have. In the theme of networking, I think one of the biggest challenges that we're seeing with many independent practices is recruitment of physicians. A lot of younger physicians are going to larger groups. I don't think it's because that's an inevitability. I think it's because they're a lot of smaller groups have challenges with infrastructure and partnership track. I'm looking at the five doctors on your website right now and unless these photos are really out of date, you've got some young-looking faces here. So it shows me that you've had a bit of success here. Talk about bringing on younger physicians, new physicians--new REIs, I should say--and what has to happen in that process to make sure it's a good fit for both sides.
NICHOLS
I think, certainly, it'd be a number of things and for us, one of the difficulties where we are is location. How many people really want to be in in South Carolina, in the southeast? So I've been very fortunate that when I broke out and opened up the practice and started privately, I was on my own for about 4 to 5 years, and it was about that time, we started looking at our first satellite office, which was going to be about 30-45 minutes away and there was a there was another city with another hospital system that was very interested in us coming over there and becoming, sort of, their infertility group of specialists and so they really worked on us about opening up a satellite office. Well, when that happened, I realized by myself, I couldn't do both. And that's when I began sort of searching for my first partner. And luckily for me, and part of this is just being, as I said, lucky and maybe blessed as well, he actually was from Greenville. He had done the military track, and was in the army practices in OB/GYN for several years and then went to do his fellowship, and then went to Walter Reed because he had to finish out his time in the military. And he was the head of the IVF practice and center at Walter Reed for three years. And of course, he's from Greenville, South Carolina, so was his wife and she finally told him, “Hey, I'm tired of moving, get me home.” So he contacted me out and at the time, we were just beginning to look. So it worked out perfectly for my first partner, and he found me actually. And so that was luck! But it was great because he's been an awesome partner in fact, he has bought into the practice, si now we are equal partners. As we move forward, every time we opened up a satellite office, it was clear we needed to hire another physician. And part of this was the third physician we brought on board was actually, he had contacted me right after I hired my first partner. He was coming out of fellowship and I said, “Well, gosh, I just hired somebody, I'm not really ready.” He was also from the southeast as well, was wanting to get into this area and he was looking at a private practice such as ours. Well, fast forward another 4 years later, when we opened up our third office, we started looking and he contacts me right away. He was in another practice in Florida and was very unhappy there and he wanted to get up this way and get into a practice setup that had a better partnership than where he was coming from. So he came into the practice and Dr. McCoy came in with a whole other set of skills. He's a very good--he's a very well noted robotic surgeon. All of the docs in our group, we still do a lot of surgeries. I like it and he's very good. So he now brought another skill set to us that help us set up our third office. Then again, when we moved into our fourth office, had another physician contact me as we were looking. He was from--he had done his training in Charleston and wanted to get back this way. So for me, it's been fortuitous, and that I've had these physicians kind of coming to me at the same time. And then the second part of that, I've been also lucky that each one of these I've hired have already been out 3 or 4 years. So it wasn't like I had to train a fellow straight out and not that I wouldn't do that, it's just when I started looking at the reality of a new fellow and the training that it takes to get them up to speed and a lot that they need to learn versus a doctor coming in a little seasoned with3 or 4 years under their belt, it made it much easier for me. But I will say the logistics of where you live and your location, it can make it difficult for hiring physicians.
JONES
Well, a little bit of a side note, we get, I mention that in many episodes that in a lot of the small markets, especially in the interior of the country, the only way that they're getting in an REI in many cases is if it's somebody that's from there that wants to come back home. That sounds like that had been the case for you. I wonder--I see Greenville on a lot of the Forbes millennial lists and places that are booming and that, you know-- I mean, look at what Denver was 20 years ago, or even Austin 25-20, even 15 years ago, and same with Nashville and I see a parallel in Greenville. and I think those are markets that are really interesting to be in because you got in early. Are you seeing that?
NICHOLS
Oh, yes, most definitely. I think South Carolina in general is really continuing to boom and grow and in lots of different ways and certainly for Greenville has become sort of one of those hotspots. You've already said it--we've been listed on a lot of top 10 lists for small time cities, but it's gone well and the growth. And so in the area around South Carolina continues to grow, certainly our area, and even in Columbia where we've opened up our fourth office. So that's been awesome for us as the population grows and the right type of population, sort of that middle class moving into with a lot of the industry in the area. It's certainly very good demographics for our business.
JONES
You talked about the dynamic of whom you're now partners with coming from less than ideal partnership circumstances. I wrote about that recently, and I interviewed four associate doctors and I de-identified all their information, wrote an article. I also talked with Holly Hutchison, who co-owns and manages a practice in Arizona about that topic on this show. And one of the issues that I see, when these partnerships or prospective partnerships break up is--I just see a total lack of expectations being firmly set, perhaps not a total lack, but an insufficient agreement of expectations. And I see that when we engage with clients sometimes. We're not asking for equity. We're just doing a regular business deal. But I still make sure that expectations are set ad nauseum that by the time we move forward with someone, they're so sick of hearing me repeat it, that by the time we're actually looking at the agreement together, we're going through it line by line, and it's the fifth time that they've heard me say this. And I've found that by doing that we have so little problem in the engagement, if we can get to that point. Now sometimes people don't want to dig that deep and so a potential sale doesn't happen because people don't want to think that much. They want something easier and just buy something. And I'm seeing that same dynamic when I hear these associates leave their practices before partnership that, Hey, we just want to make this happen. So let's do it! And then they get in and they're in for two years. And the partner has one thing in mind, the associate has something else in mind. And those expectations were just not equal. Talk about the expectations that need to be set between partners and prospective partners.
NICHOLS
Well, I think--and you already mentioned this--if you look at the website, what we have hired, at least the last three hires have been younger physicians, three or four years out of fellowship. So for me, I think what we look at for expectations and what I want them to see is that, Listen, I'm not taking this with me. Now. I'm going to retire, this practice will continue to grow, this now becomes your practice and your legacy to move it forward. And what we're looking for when we’re looking for these physicians, the expectations we talk about them is how can we grow? How can we expand? That's why we were into four offices, that's why we’re the largest practice in South Carolina. And that's the kind of mindset of the physician we want to be in. And I think that's where we've been very fortunate, that the docs we've had so far, that's what they want as well. And they realize they can be part of that growth. Because as we get bigger, then they can move up and become more of the senior partner. So I think our expectations are all about, this is what we have here. We're moving, we're growing, this can continue to grow, you can decide to be part of that or you can just decide to come on board and just be an employee and just get on for the ride. I don't have a problem with that either. But honestly, I'd rather you be invested, I'd rather you want the same vision, I'd rather you want to put the same effort in to say, Let's grow this, let's move. Let's do this. Let's do that. And that's kind of the expectations we try to put on to physicians that are here, but once again, I wouldn't fight any of them if they didn't want to be a partner. It’s an option, that's clear. But what we've been really surprised about is that every one of ours are like, How quickly can I buy in? And so we want that to happen. But of course, you know, they have to meet certain collection rates and that store to get to the point to buy in. But I mean, that's really what we're looking for when we talk to our perspective physicians looking at the practice, and we like to see that.
JONES
You mentioned that the very nature of this is something that is going to grow and become yours, I'm not taking it with me when I go. And I think a lot of practice owners would say that at face value, but it's very different to actually position the company to be able to do that versus just saying that, yeah, this will be yours. And I think what's happening very often is that that becomes secondary--positioning the company and investing in it to the point where it can become somebody else's is secondary and my retirement is first. And I think that that's part of what is hampering a lot of the negotiations for younger docs to become partners. So we've talked a lot about investing in in the practice, but what do retiring physicians need to concede in order to do that, as opposed to just say, Yeah, I've got to get this particular nugget for my retirement and then have at it. What do they need to provide for the incoming docs to actually set the practice up for growth when you're gone?
NICHOLS
Well, I do agree with what you're saying. And I think a lot of what you’re talking about are these practices are being bought out, part of that is the senior doctors who are--this is sort of their parachute to get out. They may stay on and that's fine and I have to work as hard, less salary, but they get the parachute at the front. I mean, for me, you know, I've been blessed, I've had a good career, I still have a good career, you know, I've done well, I've invested well, it's not to say I wouldn't like more money, but I didn't get into this, to try to leave the practice and try to take as much out of it when I left. I didn't build it for that reason. And that I think that may be the difference, possibly between me and maybe others. And I think that my--the junior doctors in my practice understand that and we've talked about this. There's another side of this, I have a practice and then we have four offices. I actually--my partner and I, we own the real estate, so we bought the buildings that the practices are in. So for me, I've got an income stream when I leave as well. There'll be rent coming back into my hands even when I'm not in the practice. So there are a lot of reasons why I set it up the way I did, and also when I leave, I want it to continue to go forward because I felt like we’ve built a great practice and I love to see this thing going for years. And I think that's what we've sort of discussed many times with the new docs coming in so they understand that, yes, this can be what you can do with it and it’s your practice now. There's no doubt whatever they decide to do in their time to retirement to change all that. And that's certainly the way I'm looking at leaving it as I move forward.
JONES
How has your role changed in the last 16 years? When you think back to what it was when you started the practice in 2003, what's different about your week or your responsibility or your role than it was then?
NICHOLS
if I'm being honest, actually, my life is much better now. I don't have to work as hard. When I was a solo practitioner, very hard, right? Lots of weekends, lots of time. Not much off. I brought John in, my first partner, life got better. And now when we have 5 docs, they're young, they're hungry, they want to work hard, you know? My day-to-day activity and what I do, I've got a busy enough and established practice, I do well with that, but I don't have to get out there and feel like I'm beating the bushes to continue to get more patients. And that's what my younger docs are doing. So as far as the practice side of that of this being the physician side, I'm in a very good spot. I have a very comfortable schedule, and it works well. Now, on the other side of running the practice, once again, so much of that is that it's you have to delegate. There's no way you can run 4 offices and try to micromanage it. So part of that is delegating out to the people and the different--each office having their own mini-manager so to speak, and then a head CFO, Faith, kind of running at all, and we all do it together. In reality, with the right people in place, and this is what we talked about earlier about how many people do you want to hire to do this? Well, you don't have to hire much, but you can have a whole lot more headache. I can hire more, let them run it and take care of it. I still oversee it. I have less headaches. So at the end of the day, my life is actually so much better now than it was at the start of this practice.
JONES
What are the things that you're able to do maybe as an independent practice, than if you had to answer somebody else. I know that affordable fertility treatment options for that are important to your practice, INVOcell being one of them. What are some of those initiatives that you've done as an independent practice that you're really pleased with?
NICHOLS
Well, I do think that when we look at the different options we have for our patients, you know, we first started off and we got busy and doing well we set up our own sort of IVF shared risk program. We did that independently of the different programs you can get involved with. So we did a lot of those things to help offset the cost for the patients. So we talked about affordable treatments and affordable care for these patients. Those are the kinds of things that we can do independently. We can look at those, we look at other models say, Yeah, well, we can do that. That's not, that's not a hard thing to do. And look at the numbers and figure out how it works for us, we've been able to do those sort of things. And then of course, as you mentioned, we’re now been involved with INVOcell, which is the new internvaginal culture device, which is sort of the intermediate step that's been missing for so long in infertility. Because at the end of the day, when patients come in the door, you really probably have 3 treatment options for the patient. You can put her on fertility drugs, you can put her on fertility drugs and do inseminations--both of those are relatively inexpensive, not a lot of costs, and then all of a sudden, you move to IVF. And IVF becomes the big ticket. Now, there's no doubt it's also a very efficient way to get the pregnancy as far as pregnancy success rates, but it's a huge jump in cost for patients and it's tough to come from Spain, a couple of hundred dollars to maybe $1,000, now up to $15,000 in a huge jump. And so we always were looking for what is that middle piece that we can do and people have played around with natural cycle IVF, and mini-IVFs and that sort and that's where we think INVOcell’s been a nice fit for us in our practice because you can fit it in for about half the cost of an IVF cycle. Pregnancy rates are not as good and they won't be because it's not IVF per se, but I mean, it's certainly a good intermediate rate for what we see between inseminations and IVF. So these are the kind of things that when we look at them, and when I looked at other people who are looking at and I said, this is something we're definitely interested in. So we can bring that into the practice, we can make it work. And that's nice about being independent, these are the things we can put into place, because we feel it's the right thing to do.
JONES
John, our audience is practice owners, practice managers, physicians, but let's segment it for your concluding thoughts to those that are in fellowship right now or just out of fellowship and maybe they're thinking of a move. Let's have your concluding thoughts about independent practice the potential and the future of independent REI practice, if you were talking to them?
NICHOLS
Well, I think it speaks back to what I said earlier. I think what we were looking for as we were searching for physician candidates are, you know, obviously, what do they bring to the table? What skill sets--especially those who weren't necessarily right out of fellowship? And then even more importantly, what did they want to look at for their future? Were they interested in being partners? Were they interested in having a private practice versus the others--other physicians and fellows coming out who would be perfectly comfortable to work at a hospital setting or in a big conglomerate practice as an employee? I think that for a fellow is a very important question for them is, what do they really want at the end of the day? There are a lot of people who like to be just a corporate position. I don't think there's a problem at all with that! But it becomes the mindset for you as a fellow, what is it that you truly want to look at? And what do you want to look at down the line, whether that's 15 years or 20 years from now? Where do you envision you would like to see yourself in that kind of a practice setting? Is it private? Is it independent? Is it a partnership track? Is it in another corporate group where you are an employee? And then unfortunately, some of those are so big that it's very difficult to buy-in as a partner. And so there's one of the difficulties of some of these really huge practices, but you know, other people are comfortable with being in a huge practice like that, too, and just be an employee, and I'm sure they're compensated well.
JONES
Dr. John Nichols, thank you very much for coming on Inside Reproductive Health.
NICHOLS
Good. I enjoyed it. Thanks, Griffin.
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.