The Diminishing Returns of Fertility Business-to-Business Marketing

It’s just B2B fertility sales. How many challenges could there possibly be?

Oh, not many, just...

1. Fewer qualified prospects 

2. Limited time and access

3. More gatekeepers

4. Long sales cycle

5. Short sales window

6. Detached point of sale and

7. High regulation

Other than that, I can’t think of a single reason why it would be harder than ever for companies to sell to fertility centers. In other articles, I'll address why lack of change has relegated many B2B fertility companies to commodity status. Here, I will attempt to define the principal challenges that fertility companies face in marketing and selling to fertility centers. I will also try to explain why these very challenges inhibit fertility organizations from investing in alternative approaches to solve them.

1. Fewer prospects

Stat News reports more than twice as many private equity affiliations were made among REI and OB-GYN groups from 2017 through 2019 than were made in the previous seven years. For some companies, this means huge customer growth. For others, in certain cases, it means half as many potential customers when networks negotiate exclusive deals with other vendors. 

2. Limited time and access

When the groups are larger, the dynamic usually changes to an enterprise sale where there are more decision-makers (though many small fertility practices have the characteristics of an enterprise sale). Even when there is still one principal decision-maker, she or he frequently needs the blessing or inclusion of many others. When committee decision-making takes over, it only takes one skeptic to derail the verdict. Most of them are gatekeepers.

Among independent fertility practices, who are often the most viable prospects, the senior partners’ responsibilities as physicians almost always take priority over their responsibilities as business owners. I agree with Dr. Paco Arredondo that physicians have the intelligence and training that can set them up to be entrepreneurs, but I agree by Dr. Andrew Meikle’s definition, that most of them are not. I won’t go into why--I wrote a four part series about why most fertility practices are not entrepreneurial ventures--but this business owner-physician tension greatly reduces the time that they have to make business decisions. When they have so little time to focus on the core responsibilities of a business, they often delegate the duties without the autonomy. Also, gatekeepers...

3. More gatekeepers

Fertility sales reps often view gatekeepers as administrative assistants or receptionists. Here is a more encompassing definition of gatekeeper that will better direct your attention to the access you need. A gatekeeper is anyone who cannot say “yes”; they can only say “no”. 

4. Long sales cycle

It can take months and sometimes years from first meeting to when the client is actually ready to purchase. They have construction delays, breakups with partners, and sometimes they wait for the pain to hurt worse. It usually takes a long time to get in the door, wrangle stakeholders for follow-up meetings, get the yes, the signature, and finally get the payment. 

5, Short sales window

It’s “hurry up and wait”... until it’s “hurry up again”. A practice is opening up now. They won’t need another office for years. They may never need another lab. They only buy this type of equipment every several years or even a couple of decades. They just got out of a network affiliation and hopefully, they’ll never have to do that again. The short sales window is the yin to the long sales cycle’s yang.

6. Detached point of sale

You don’t buy an IVF lab at the click of a button. There isn’t a single digital point of sale for many business dealings in the fertility field. Because of the long-term relationship dynamics of the enterprise sale, single-source attribution of marketing efforts is sometimes impossible.

7. High regulation

For some segments of the “fertility industry” the disclaimers have to be longer than the content. There are some limits to interactions, joint ventures, and messaging with and to physicians and practice owners.This difficulty may be obvious but the challenge compounds because it prevents many companies from making the necessary move to being a media company.

CAUSE OR EFFECT?

These seven challenges have certainly made your job more difficult. Still, it’s the (not so) strategic response to these challenges that compound the sales pain many fertility companies are feeling. The solution involves brave decisions in positioning and the activation of the position by putting forth oneself as a media company. I’m not talking about putting out a couple of webinars. Be sure to subscribe to Inside Reproductive Health and Fertility Bridge to be alerted about the coming content that describes the solution in more detail. 

Read about how we help B2B fertility companies differentiate themselves and increase sales here.

113: Building Out an Effective Referring Provider Strategy

In the latest episode of Inside Reproductive Health, Stephanie and Griffin explore if MD & DO referrals are still king or have been overthrown by internet resources as top referral sources. Knowing where most referrals come from can help you build an effective strategy to capture more new patients and convert those referrals at a higher rate. We also layout 6 pillars for an effective referring provider strategy that you can either give to your physician liaison to start implementing or outsource to a company like Fertility Bridge. At the end of the day, if your PL does not have a system, you are leaving money on the table.

Listen in to the full episode to learn:

• The 6 pillars of an effective referring provider strategy

  • Make sure your reporting is in line and cohesive

  • Ancillary services

  • Building the right content

  • Having the right events

  • Outreach of referring sources

  • Converting referrals that come to you

• The % of patients actually referred by a doctor (and what that means for your clinic)

• If a physician liaison is needed

• How to attribute referral sources properly
  

Additional Resources:

Referral Pattern Blog Post: https://www.fertilitybridge.com/inside-reproductive-health/the-6-pillars-of-the-fertility-referring-provider-system

To learn more about our Goal and Competitive Diagnostic, visit us at FertilityBridge.com

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Transcript

Griffin Jones: [00:00:40] On today's episode, Stephanie's on, we talk about our six pillars for referring provider strategy. It's important to get these right before you hire a PL if you're thinking about that, if you're a big company, you've got dozens of PLs, it's important to get this right. And in working in this framework to make sure that you're getting the results that you want before I get into this topic, today's shout out, goes to Dr. Paul Lin from SRM in Seattle, because go Bills, that's why in today's show, we talk about these six different pillars of why it's even important to still address physicians as the referral source that they are, but not to put them on the pedestal of being all or nothing. Talk about the facts beyond that and then we break down each of the six pillars even more finitely. So I hope you get a lot of actionable advice from this episode. Let me know if you need any help and enjoy.

Hi, Stephanie. 

Stephanie Linder: [00:01:38] Hi Griffin. 

Griffin Jones: [00:01:39] Welcome back to talk about referring providers. But before we get into that topic, I do have to tell you that I got a call from someone that I'd never met before. A doctor on the complete other side of the world who listens to the show. And we were talking about other topics, but one of our more recent episodes came up and he said that he agreed with you about the referring wellness providers being listed on the website. And I knew most people were going to agree with you. I even said that in the episode, but I also knew that it would stroke your ego if I brought that up. 

Stephanie Linder: [00:02:15] Yeah, it does. So thank you for sharing that. That's a good start to the podcast.

Griffin Jones: [00:02:18] Yeah, well, now I have to find something to ruin it for you and be pedantic about something to be right about and catch you off guard later in today. But we are in your wheelhouse about referring providers. So I might have my work cut out for me. The reason why we're talking about referring providers is because I've seen the attitude shift from  even when I first started talking to people in 2014, 2015, still many people thought that referring providers were everything that all the good patients came from referring providers, that it was like, it was almost singular as a referral source. And now I'm hearing people say that it doesn't matter anymore. And that's just not true either. I've kind of seen the pendulum swing here and we have some facts. We were doing an abstract.

And then in spring of 2020, when the world started to go, we were going to submit it to ASRM 2020. And then when the world took a turn, I decided that was not anywhere near the top of our concerns at the time, but we did get 250. Responses from REI patients, all people who had done at least one consult at an REI practice from all over the U S and what were the facts that we learned from them?

Stephanie Linder: [00:03:38] Yeah. So we asked these patients several questions and one of the first questions was, were you referred by a physician? Yes or no. And 60% of the REI patients said, yes, they were referred by a physician now that's still a lot, but it's still very far, of course, from a hundred percent. So then we asked another question, okay of all the different ways you can learn about a practice, so physician referrals, online search, you know, online reviews, there was seven or eight options, which of these were the most influential? And what was really interesting MD referrals while still number one, only 21% of people said that was the most influential and what was number two and three was also really important data.

So it, number two was location coming in at 20%. So neck and neck with the MD referrals, and then number three was recommendation from a friend or relative coming in at 19%. So very interesting to look at this data in this way.

Griffin Jones: [00:04:41] So Step another way, 40% of your patients on average are not being referred by a doctor at all.

And that's huge, but it still is really important. It's still 21% of people say that it's the most important physician referrals are the most important influence. Their decision of an REI practice. So that's still important, but it just a lot closer and a lot more segmented than we may have otherwise thought.

And I know that I have to make an important disclaimer here, which is when Stephanie and I say MD referrals. We mean physician referrals. We mean MD and DO referrals. There's a couple of DOs listening that are like, what the hell, man? Sorry. That sometimes really. It's just quicker than saying MD and DO referrals.

And then we don't have to say physician referrals, doctor referrals all of the time. So that's an important distinction to make you have multiple reasons that people are selecting the practice. You do need to know which is the single most influential. And that's why you have to do multi-source attribution.

So many people listening are doing single source attribution. You're asking people, how did you hear about us? I'm sorry. That's a very dumb question. I've talked about this on the podcast before I've argued with Rob Taylor about it. Who's an amazing marketer and you should listen to his episode, but single source attribution is like saying which beer got you drunk after you've had 12 beers. It was the 12th beer that got me drunk. Well,  sorta, but not really. And so when you get the best of both worlds in multi-source attribution He's asking people binary. Did you see or hear us  hear yes or no? What about here? Yes or no. And then all of those different options become the options where you ask of all of these, which is the most influential in making your decision.

And when you do that, you can start to see your patient's referral patterns change over time. So you don't swing from MD/DO referrals are everything to, now the internet is everything. You can see the nuance and the truth is that people  are coming to you from a lot of different ways.

And they're making the decision from a lot of different ways, but they tie in together and you need to be able to see that now that we've shown you, that it's not the most important, but, or it's not exclusively important. It's irresponsible to view it as exclusively important. Physician referrals still are super important.

We're here to talk about that strategy because of it. What are the six pillars that build a referring provider Strategy. 

Stephanie Linder: [00:07:24] So the six pillars that build our strategy around referring providers are number one. You have to make sure that your reporting is in line and cohesive. And we'll talk about that.

Number two is all the ancillary services. That's inclusive of things like semen analysis and HSGs and getting those ready to go. So OB's or any kind of physician can refer very easily to you. We'll talk about that as well. Number three is building the right content and number four is having the right events to promote and support that content.

Number five is the outreach with all of the referring sources and number six is actually making sure and following through that, those referrals actually come to you and convert. 

Griffin Jones: [00:08:10] We're going to go through these six different pillars. And it's important to do that because one of the questions we get asked all the time is should I hire a PL or not?

And that's a secondary question first is that you have to have the system. Then you can decide if you need one person, if it's worth it, having one person working that system most PLs will not be able to just set up a system like this. Some will, some PLs are worth their weight in gold. I think that many PLs are walking billboards and you're straight up wasting your money on them, but some of them are true physician liaison. So they are actually the liaison of the relationship between yourself and the other physicians in your area. They should be treated like gold. They should be compensated well. And if you're listening and that's not, you come work for Fertility Bridge because we're going to be, we're going to be opening up that client operational marketing seat to be its own position.

I might even already have that commercial in this podcast. I don't know if it's done. But Steph gotta be busy managing accounts. So if that's you and you want to do that for multiple clinics, you can come work for us. But for most people, I just don't, they're just not good at they're walking billboards.

So first before we hire somebody to go do that, we have to have them in a functional system. And then you don't have to worry about the walking billboard part, either fulfill the system or they don't. So what is reporting built from Stephanie?  

Stephanie Linder: [00:09:38] So when we look at reporting, we want to be sure there's very specific KPIs that are enjoined with it.

So here, we're looking at two specific KPIs. So what is your new patient volume and what is the total number of referrals, but within that number of referrals, we also want to look at the percentage of attribution, so the patient reporting. So these are the things that we'll focus on and you want to make sure that everything ties up to these two things. I guesse.

Griffin Jones: [00:10:07] And if somebody is listening, Hey, that's three KPI's. It's like, well, oh, well there's two main ones. And one of them gets split. So if your practice or your goals, aren't large enough to do a lot of outreach. Then you just need to measure these two things you need to know, okay, what are my new patient volumes easy?

And then I need to know the number of referrals, but they should be measured against each other in the ways that Stephanie says, if you don't have such big goals for growth, you can more or less stop there. You don't even necessarily need to do the rest, but before you put any substantial effort and resources into outreach, you should be reporting on activity across a few different categories.

So, okay. So we've got the main things to report on volume referrals and how referrals are split up. But once we decide we're going pass, what we're actually going to be doing enough outreach. Then we need to be monitoring the results of that activity. And you could break that up into six categories, which are what Stephanie?

Stephanie Linder: [00:11:14] So there's really three main reports. You will, of course, want to look at the people that are referring to you. And within those that are referring to you, you've not want to, not only want to look at the practice level, but you also want to look at your top 20 providers. So I say top 10 practice, top 20 providers.

And the reason is that there will be some folks that there's only an, a practice of 10 OB GYN, maybe only one is referring. And so they would normally fall down to the bottom of the practice lists.  But if you also look at it for providers, you can target and, you know, change your strategy a little bit to get that top referring provider, to start speaking to their partners and kind of spread the referral, use them to spread the referral patterns within that OB practice.

So that one is the most important, but I was the second most important is who are your targets for those that don't refer so same strategy. We need to look at the top 10 practices that don't refer. And then who are the top 20 providers that you want to target, whether they're in or not in that practice?

The next one is something that I don't see our clients do very often, so I wanted to bring it up. Who do you share patients with, but they have not referred? So all of your patients that get pregnant will need to, well that most will need to be sent back to an OB GYN for care and graduation. Very often those folks that you send back to, if they're pregnant, if they have successful pregnancies, you're naturally having a word of mouth referral and building your brand and reputation.

Hopefully your patient is speaking highly of you. But I was always shocked that people don't look at this list more often, because for me that would be the lowest hanging fruit. Hey, I'm sending patients back to why aren't we starting kind of a circle of referrals. So that would be the third, a report.

Looking at it again in the same way, both at the practice level and then also at the provider level. 

Griffin Jones: [00:13:23] I want to make that distinction for the listener too, because it wasn't immediately obvious when you and I were first talking about this, the referring targeting, not I thought, well, what's the difference between the non referring target at first?

And of course you could use this non referring patient sharing group to inform your target list, but it is kind of different, it's you have people that are, because we know that 40% of people are not being referred by a doctor. Well, they're still going to an OB when they have to deliver, they probably have a gynecologist, and those are the people that you share patients with.

And so if they're not referring to you, you still have that common patient that you can use to build that referral pattern. That was an important distinction. That you made that I think makes sense. If people want to see this visually go to the Fertility Bridge blog, you can see this article where we put in the different columns.

So you can see the different axes between practice and provider and then referring non-referral target, non referring and sharing patients. And so. If you're doing all of these things, you want to record them in you want to record your activity in a CRM. If you have somebody that's out there calling on these people and they are actually working a top 20 and top 10 lists for all of these, that's a lot.

You want to record that activity in a customer relationship management, a HubSpot  or Salesforce, you record the results, meaning who's actually referred in the EMR that, so if you've got your reporting set up, then we can start to look at other things that bring in referrals and what comes next on our pillars.

Stephanie Linder: [00:17:44] So the second pillar is ancillary services. And I want to share a statistic that I love sharing with our clients and really is kind of an aha moment is that 30% of patients that see your practice or a referral semen analysis or HSG will return to your practice for fertility consult within one year.

So this is a huge opportunity to get a referring MDs used to your practice. A lot of clinics don't do these ancillary services very well. Painful. So if you can make this process seamless, you will win over a new physician and it's a great entry point to get them to build trust and start referring for that initial consult.

 Griffin Jones: [00:18:27] So what are the steps in order to build that offering? 

 Stephanie Linder: [00:18:32] So we broke this down into four steps. The first thing is you just have to begin accepting outside semen analysis and HSG referrals. Most clinics do this, but I'm always surprised at folks that don't have an HSG machine or don't necessarily have andrology on staff.

So first make sure that's available and offered at your clinic. Second you want to promote that separately separate from, you know, the typical marketing brochure or patient facing brochures you drop off, you need specific content, and we'll get into that a bit later that promotes these services.

How do you send a semen analysis patient? What's the turnaround time? Make that very clear and contents. The third would be to provide a really good service. So your turnaround time at maximum to get these results back to patients. Should be 72 hours, if not sooner. And the fourth is educating these referring providers on what to do with these results.

And this can come in a lot of different ways through content, through events, through consults. I see a lot of people use our advanced providers to share this information back with the referring providers clinics. But it's clear that you educate them and be that source of education so they can begin to build trust and credibility.

So you can begin to build trust and credibility with these referring provider sources. 

Griffin Jones: [00:19:53] Okay, so we've talked about reporting, we've talked about ancillary services. What's the third pillar? 

Stephanie Linder: [00:19:57] So the third pillar is content. So once you've identify these ancillary services, you need a way to promote them as I referred to.

So you need to create this content, but even before jumping into the content, you need to make sure your foundation is set and you know, your brand guidelines are set. If that is not established, you need to work with fertility range, our work with your marketing team to make sure those brand guidelines are crystal clear.

But if that is establish, what you want to do is make sure that you pull out there were the three unique differentiators of your clinic, be of interest to the referring provider. Now I'm not talking about the same three differentiators that you talk about with patients, although it's quite possible they can overlap, but the three differentiators will fall into three categories.

And these three categories are your performance. This is an encompassing of success rates. What unique technology do you do? What happens differently in your lab? Is there anything unique with embryology? The second one will be all about the patient care. So this is where you get a chance to talk about your staff.

You as a physician and the way you communicate with patients. And then the third is the access to care. So are there financing options? Is it easy to get an appointment? Do you take a wide variety of insurance or if you don't, why don't you? So those. Differentiators are he to pull out again that are different from just the unique differentiators that you talk about to your patients.

Griffin Jones: [00:24:08] And this is where you can get really creative with things too. It's not just the pamphlet anymore. And I think you've all gotten the idea now that you're seeing so many of your colleagues destroyed Tik TOK and destroy Instagram that oh, doctors really are using this social media platforms. The rest of you that aren't doing that are using LinkedIn, like it's 2010 Facebook.

And so your doctors are in these places, this word is where you use your creative, because you're going to put them in different places, your referral pads, your referring provider page, which should be on your website. You should have a differentiator checklist, a preconception panel, and then how to interpret the essay guide.

And if you want to talk about that last one, I'll yield the floor to use absence. You said often find that's something that's missing. 

 Stephanie Linder: [00:24:59] Yeah, absolutely. So what often happens, not every clinic, but a lot is that they'll send the results of the seam and analysis back to the provider. And the patient is just unsure where to get the interpretation of the results.

Every REI listening to this podcast will agree with this when, how many times does a patient call you and can you give me my results of the semen analysis and your staff is tasked with no, you have to go to your OB for that. And that patient is very confused and that I've seen that lead to bad reviews on the fertility clinics page when it's not the responsibility of the REI, it's a responsibility of the person who ordered the semen analysis.

So the point of this all being is that if you can educate your OBS through written content through a guide, Through a video that says, this is how you talk about the semen analysis results with your patients. This is what a total modal count means. That will just prevent that from happening, which has such a ripple effect into your community, your referrals, your online reputation, et cetera.

So when Griffin talks about, you know, the pieces of content. That one is one of the most key ones that is not really done well in most clinics.  

Griffin Jones: [00:26:17] Should all be cogent with the rest of your marketing. You shouldn't be here's doctor outreach over here. That's just something we do to, we call on people. We invite them out to dinner every now and again, it's part of your brand.

It's part of the content that you create and getting creative is really important to have creative people and in messaging. These things is what helps you get apart from the herd that is doing the exact same things and having the same diminishing returns. So once we've got our content, now we can use that as a baseline for events, which is our fourth pillar, when you've got really good content, then you can create events about that. About those. And so what are some of the different events that people can build upon beyond lunches and dinners? 

Stephanie Linder: [00:27:10] Right. And I'm glad you made that caveat Griffin, because I think a lot of folks just think, you know, for sales reps or PLLs or physician liaisons that, oh, they just do lunches all day long.

And with the advent of COVID, all of a sudden folks are like, oh, there's no access. And they've given up, well, it's time to get creative. It's time to stop using lunches can be good strategically, but it's time. You know, just throwing $400 at the window and seeing what sticks. So the four events that you can leverage is the provider to provider meetings.

One-on-one I know we want to be useful of your time as a provider, but that sometimes they'll go further. Even if it's a virtual meeting than a lunch with 30 staff and no doctors. The second is provider to group visits. This can absolutely happen. And where a lunch strategically would make. But also a lunch does not always have to be done.

It could be something coffee in the morning, a snack people also just want to come and meet the provider for educational value. So if you can come and give them some kind of value or something, they'll learn that they can take to their patients. That's where you'll see the most ROI. The third is open houses.

I know Griffin, you challenged me on this a little bit. People want to see what happens behind the curtain, AK in the lab. And if you have a beautiful space, you have a lab with really cool technology. It's a huge opportunity to show this off, now this would be strategically used with a new doctor, a new location opening.

But I still think they are very useful and the last would be single topic, educational events. So it ties back to what I said is that OB's and you know, sometimes primary care providers, wellness providers are desperate for education around fertility. So if you can say, look, we're doing a virtual event, an in-person event, we're going to talk about, you know, the five markers that you need to look at for your fertility patients, people want to come to that. They want to learn and they want to meet you. So make it valuable. 

Griffin Jones: [00:29:09] All four of these can be turned into they can all be in person, they can all be virtual and go ahead and turn them into a lunch and dinner. If you want to. All I'm saying is the content of each of them should be good enough that you don't have to be buying somebody lunch or dinner if it's not relevant.

Okay. So we're making our way through our six pillars. We've talked about reporting. We talked about ancillary services like HSG and essay. We've talked about content. We've talked about the events that you build. Upon and beyond that content. So what is the actual outreach like? 

Stephanie Linder: [00:29:42] what's important to know as even with the best physician liaison in the world, especially as a newer practice, new location, new doctor, no one can replace the true REI and their relationship with a physician.

So your reputation must be trusted in order to really build and accelerate the referral network. Bottom line is you need to be accessible. You need to be present and you do need to communicate with these referring providers. So there are some places where the PL just can't fit in for you or replace you.

And so this would be allowing residents to do rotations. Just this, the relationships you have with medical schools, shadowing, and coming to visit your practices because eventually those. The OBS of the future. All the relationships that you made in residency are so valuable as you go into your future practice, our into your practice.

And the third would be your memberships in the specialty society. You need to show up to those. That's crucial to make those relationships after hours. And then also it's the grand rounds and the journal clubs. Again, you're educating the doctors of the future. And so what you do now does pay off three, four years down there.

Griffin Jones: [00:31:03] It's this ties into the content via events and everything else. Because as a referring as a physician who is referring, it was being referred to by other physicians. It's your relationship. And the more that you have to build upon and include the rest of your team and the rest of your practice, the more you are extending that relationship of which someone else can be the liaison.

And even though it's not your field, you can kind of get the example from what Stephanie and I do. Many people bought  Fertility Bridge for Griffin because people heard me on the podcast, et cetera. But guess what? I don't manage accounts at Fertility Bridge, Stephanie does and part of the reason that we're able to make that transition is one Stephanie's in the first sales call with people.

So even before somebody becomes a true client or at least in the goal diagnostic, She's in there. And so people are meeting her. If we decide somebody's going to move forward, we bring our project manager into this second meeting so that they're meeting these folks before we even move on. And since you haven't been on the podcast, Stephanie people are prospects. Oh yeah Stephanie, she's on the podcast with you. And so it's even more familiar to people. So you were including these other people with you in the content so that you can distribute the relationship. 

And it's almost like a boomerang with the content, because not only are you  being featured in the content, you're also contributing to it. And you're also getting your orders as far as our philosophy from it. So you're contributing, you're receiving and that's should be true for the entire group.

So all of our points of view, we are really firming out as you've been able to see. So when. Stephanie's talking to somebody there's a lot more for her to go off of Fertility Bridge knowledge than just, oh, this is what I think Griffin would say. And so by you really participating in the content in the events, you're creating a cannon, a Bible, or an authority for which your people can both contribute and they also have their orders to go off of from there. So I harped on that for a little bit, but I just don't think it can be stressed enough. You are the person from which people have the relationship. They don't want to make the substitute if you just drop it on them. But if you bring in the other people and they trust them, then it's a much smoother transition and you can do it too.

From the ways that we talked about the ways that your PL is going to do this is through total office calls, updating the target accounts, they should be also updating the wellness providers. They should be touching these people twice a month. They should be doing the coordination of the content and events, and they should also be checking up on those referrals after those events.

So that brings us to our sixth and final pillar. What is referral? Follow-throughs Stephanie? 

Stephanie Linder: [00:34:13] Yeah. I want, we'll get into that in a second, but Griffin, I want to make a point too, is that when you say, you know, your senior physicians bringing in. There are supporting staff. It's of course it's a physician liaison or the marketing team if they have it.

But this is also great for when you have a new physician, join your practice, you as the seasoned physician or a medical director, bringing the new physician in almost as to say together. Like you can trust them, just like you trust me. And that's also how you start to build a book of business and see the ROI on that new fellow or that new position.

And you almost give your blessing. I think that's really important because that's a really important thing to any medical director that is hiring new doctors. Like they need to get them busy as quickly as possible. And that's one way. But going on to the referral follow through is, okay, great, we're getting people to refer to you now. It's how can I, how do we keep them happy? So there's four key things that you need to do to make sure that this follow through happens. Kind of going old school with the first one is sending a thank you note for that first referral. Now we're talking about people who have never referred to you before and start referring.

So the old school written thank you, notes, Griffin. I know you're a big fan. But it goes a very long way and people just don't do it anymore. So Hey, Dr. Jones, thank you for the referral. The second is just making sure that you are tracking your semi monthly touch points twice a month in your CRM. And you're checking in, you know, this is what's updated with your referral.

This is some new collateral we have, et cetera. The third is the  post console or referral note that is sent back to the OB or primary care doctor immediately following the patient's console. 

Griffin Jones: [00:35:53] Talk a little bit about how that's different from the thank you note? 

Stephanie Linder: [00:35:57] So thank you. Note comes after, you know, you get the referral, let's say, you know, your PL or you as a physician or whomever, it shouldn't be checking weekly to say, okay, Dr. Jones sent me a patient for the first time it's marked in the EMR. Great, I'm sending them a thank you note right away to say this patient booked their console, thank you so much, you know, you don't have to get as detailed, although some people do to say the consult actually in six weeks, we'll keep you updated.

But the post consult referral note six weeks later when that console it happens with the physician. It's the physician's duty to say, okay and they have their specific criteria, again, we don't want to get too clinical, but there's specific criteria that say, okay, this is what they were diagnosed with, this is what we discussed. This is their plan of treating. And maybe they even less, like some of the genetic testing that they're planning to do, each clinic will be a little bit different, but it's basically a note to update the OB so they can keep it in their records to say, okay, my patient, I referred them.

They actually had the console. This is what they're moving forward with, whether it be IVF, third party services, et cetera. So it's a way to keep them updated on their patient. And then a way for them to know that eventually they'll be coming back to them for pregnancy care. So very easy to do this when you're a new practice or you're not busy.

This one often gets pushed to the side as a practice gets busier. And so the key is to create a workflow in your practice that this is templated a bit, or this becomes a part of your operations and it doesn't get pushed to the side. Once you get busy. 

Griffin Jones: [00:37:34] There you go, there are your six  pillars for referring provider strategy, reporting, ancillary services, content events, outreach, and the referral follow through. You need this system before you hire a PL if you're thinking about doing that, if you have a PL or multiple PLs, and you're not seeing the results that you want, or you have no idea what the results are its because one or more of these pillars are broken in the system. If you would like Stephanie and my help and Fertility Bridge's help, we can talk about that in a gold diagnostic, $600. It's quick, it's easy. You can make sure your people are on the right track. And hopefully this podcast was $600 of value just listening to it, Steph, thanks for coming on and going over this with us. And I look forward to getting into more detail in future episodes.

111: Stay Culturally Relevant by Learning from All Generations with Dr. Angie Beltsos

This week on Inside Reproductive Health, Griffin Jones and Dr. Angeline Beltsos go down a thread of the multi-generational value that happens from colleagues mingling with each other. It’s important for an organization to learn from both the young and old to gain fresh perspectives. Organizations that do this well have many short-term and long-term benefits like being able to recruit well and staying culturally relevant long-term.

In this episode Griffin interviews Angeline N. Beltsos, MD. She is the CEO and Chief Medical Officer of Vios Fertility Institute. She is double board-certified in Obstetrics and Gynecology and in Reproductive Endocrinology and Infertility (REI). Dr. Beltsos is also part of the Clinical Research team at Vios and participates in a number of research projects and scientific publications. She has received numerous awards in teaching and has been honored as “Top Doctor” from Castle Connelly for several years. Dr. Beltsos is the executive chairperson for the Midwest Reproductive Symposium International, an international conference of fertility experts.

Topics discussed include: 

• Learning from different generations

• Principles of leadership

• Leading as an executive

• Recruiting younger doctors

• How to be culturally relevant while aging
  

MSRI Conference: https://www.mrsimeeting.org/

Dr. Angeline Beltsos’s Information: 

LinkedIn: https://www.linkedin.com/in/angie-beltsos-b33a846

Facebook: https://www.facebook.com/angeline.beltsos

Website URL:  https://www.viosfertility.com

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Transcript

Griffin Jones: [00:00:00] [00:00:00]Today. I talked with Dr. Angeline Beltsos about what it's like to start a meeting in the field. Hers is the Midwest Reproductive Symposium. What that entrepreneurial venture is like, and the benefits that come from that collegiality and from the networking that allow people to do business. Before I get into this topic with Dr. Beltsos. Today's [00:01:00] shout out, goes to Hannah Johnson, my friend, who's the chief strategy officer at  we're speaking together at MRS. So she gets this shout out. Hopefully she hears it in today's interview with Dr. Beltsos. We go down a thread of the multi-generational value that happens from colleagues mingling with each other, learning from different generations and the principles that, that takes into leadership in leading as an executive and also following by learning from the next generation, this turned into be a lot more philosophical than I was necessarily thinking, but we talk about the short-term benefits, like recruiting docs. It's going to be a lot easier. For you to recruit doctors and staff doing some of these principles, but also the longer-term headier stuff of being culturally relevant well into old age. I hope you enjoy this discussion with Dr. Angeline Beltsos.  Dr.  Angie welcome back to Inside Reproductive Health. 

Dr. Angie Beltsos: [00:02:04] Thank you for having me.

I'm so excited to be here. 

Griffin Jones: [00:02:07] The first time you were on, we talked about your entrepreneurial tendencies. We're going to talk about those same tendencies today, but applied to a different venture. Last time we talked about the Vios empire, what it was like to start a group, but this time I want to talk about a different venture that you started as far as I remember, and that is the Midwest Reproductive Symposium. That is an in-person now a hybrid in-person and virtual meeting, but it had been in person for years. And I want to talk about how that got started and what possessed you to do it. So let's start with what possessed you to do. 

Dr. Angie Beltsos: [00:02:47] Well, I had just started career after fellowship. It had been a few years and varying pharmaceuticals. One of the reps came and said, why don't we do a meeting in Chicago? We had the ASRM meeting, of course the national meeting. And then, California. We have the Pacific coast fertility society. And they said, why don't you do a meeting in the Midwest? And we can call it the Midwest Reproductive Symposium, the MRS meeting. And, here we are several years later .

Griffin Jones: [00:03:24] But why did you want to do it? I mean, reps probably come to you with half-baked ideas all the time. I've come to you with half-baked ideas before, so you could turn around, turn away or launch into any of them, I suppose. Did this one seem good enough to you? 

Dr. Angie Beltsos: [00:03:39] It seemed like filling a void. Although a lot of people go to a big meeting, like the ASRM meeting or SRA with thousands of people. And we get to see all our friends and learn the latest. It's also ironic that when you're in a big meeting, sometimes you don't get as much out of it. You don't get to. Actually speak with some of the thought leaders and, make new friends. And so the idea of having some of the thought leaders, not only in Chicago, cause we called it the Midwest meeting, but it was actually the place where it was held, not where all the attendees came from. And we had , immediately a national attendance and really some of the thought leaders in the world. It's an intimate setting. One in which we. Do have it at the Drake hotel where we have probably a max of around four or 500 attendees with that though you have a certain vibe that comes with that. There's a lot of opportunity to not only learn science, which is very important and be motivated to take some of that. Back home, really to change how people practice fertility and keep it modern and fresh and forward-thinking, but also to make a friends and colleagues that last not only for that meeting, but for a lifetime. So when they came up with it, that was sort of. Be relevant. 

Griffin Jones: [00:05:15] And you're right. People do come from all over. That's a nice thing about it being in Chicago is it's kind of easy to get to Chicago from anywhere if you're in the U S Chicago central. And then if you're not in the U S well, it's only an hour or two more for you probably than it would be any of the other major cities at most. So it's really central place. You got people from all over, but at what point did you realize that this was gonna be. You taking it on.  Did you know that from the beginning or were you thinking that, okay, Faron, go ahead and do this. I'll come and be the token REI. And what point did you realize that this was your baby. 

Dr. Angie Beltsos: [00:05:53] T minus,  six to nine months when the whole thing started, it was going to be something that I organized. With the, you know, some of the faculty that was with us and some of my colleagues, but they were like, all right, you're in charge of this, go at it. So we, I went around and I was like, who's really a heavy hitter today. And who are some of the thought leaders in the United States? And they were like, well, call them all up. See if they'll speak. So one by one, I called each person and everybody said yes, which was really surprising. I was like, hi, I'm Angie, do you want to speak at my meeting? They're like, sure. Hold on a second. I was like, Hey Richard, Scott, will you speak at my meeting? They were like, one moment, please. This is Richard. Like, yes, I will. I'm like, oh, okay. Bill Schoolcraft, will you speak at my meeting? Yes, I will. I was like, okay, then see you in June. 

Griffin Jones: [00:06:53] So this was 2003. That was the first year? 

Dr. Angie Beltsos: [00:06:58] This was. I guess it was '03. Huh? 

Griffin Jones: [00:07:01] That's what the website tells me that's before my time here. So I'm going to take the website for its word now, at what point did you start to build like committees and have recurring people in the beginning? It's like, okay, I'll call the people I know and ask them to be speakers how did that turn into like you have other people planning specific. 

Dr. Angie Beltsos: [00:07:24] Parts of it. Yeah, you know, it's a great question. We started with a meeting planner and me, and then she said, well, why don't you ask,  you know, some of your friends and colleagues who they think would be really important and relevant, so there was sort of this informal committee that she and I talked about and an organized, and she guided me for the first five years, Ferring was exclusive as a sponsor and they were. You know, an unrestricted educational grant. So they weren't really involved in the topics at all.  And you know, very much saying, find the best speakers, the best topics. So really high quality, I think. Things that were coming out as new things to consider doing in, in our field. And we had we had a blast, but over time, I would say the first year we had some of the speakers like Barry bear and bill Kerns, they said, why don't you ask them to be part of your committee? So we were about three or four people in the first, several years that started to help think through this. And then the people that were involved also came up with great ideas. They said, well, why don't the nurses don't have anywhere to go? Why don't you have a nurse program here? So we started the nurse practicum and then, a lot of the business minds in industry said you don't have really anywhere for business people to meet.

Why don't you do a business program? So we came up with a business minds. And this one , person was really interested in mental health and said, there's no place for mental health in any of these programs please. Can we add it in? So we started the mental health program and we thought there's no better place.

If you've got all these incredible people together, why not have some of the students of fertility? So we added in the. Reproductive endocrinology and infertility the REI fellows program. And they've been a strong part presenting their research and getting to know them. And it's funny because in the beginning, the students are they're learning, but then soon the student becomes the master.

Griffin Jones: [00:09:52] So, how do you get some of these people to keep coming back and chairing their specific segments? Because some of the people you've had for years and years. So how do you keep reeling them back in? 

Dr. Angie Beltsos: [00:10:04] I think that when you want something to be sticky in your life and you want to keep people engaged, it can't just be about black and white things.

There's some very important things about a meeting and. Only what you're saying, not only what you're doing, but how you make people feel like the Mio Angelo quote. And I think that becomes very important. So we are so intentional to make sure that people like Griffin Jones when they come to the meeting.

Yeah. You learned a lot, you made some new connections, but you also. Had a blast, hopefully, and music and time to socialize is very intentional people often say, oh, well, you know, why do you have all that in the meeting? But it's so important to make people feel good about coming back. 

Griffin Jones: [00:11:03] I think it's one of the things that binds all of that together.

Like you said, there's a fellows track. There's a business minds program. There's a nurse practicum there's for program for doctors and scientists and the size of MRS, and the social events bring it all together. It's a very good place to build relationships. I love ASRM. You can get more business done in four days of ASRM than you can four months on the phone.

In many instances, that's true for almost everybody across the field, but there's something about MRS. Where it is very good for building relationships. When I think to some of the strongest relationships that I have with docs and with other people across the field, it started there in Chicago. And I think it is this.

It is because you can go to one of the mental health talks and then you can jump over to another track if you want. A lot of people do the same track the whole day, but there are, there is so much programming for everyone. And then it's all tied in at the end of the day and Chicago. In June when it normally is in fantastic this year, it's going to be September, which is the other end of fantastic for Chicago weather is why you're not having it in June.

So let's talk a little bit about the changes that you saw. COVID happened. I mean, I imagine in early March you were kind of like everybody else, oh this isn't going to affect us. It's too far off. And then two days later you're like, 'no' it's definitely gonna affect this one in the next one. What was that like adjusting for COVID? 

Dr. Angie Beltsos: [00:12:38] I think like we were at Vios. ,sometimes it's good to be lucky. And we had thought very importantly about being nimble, being able to switch gears and pivot quickly. So when. All of this started to unfold. We didn't know if it was going to be two days, two weeks, two years, you know, sitting here talking to patient by patient, but for the meeting, we also felt it was going to be very important to be relevant and to continue.

So we were the first meeting to go in the fertility world to go into a virtual setting. And we just said, pivot and go. So we did our meeting in June. By zoom or by a video conferencing. And it worked out beautifully.  All things considered. We had great attendance and really used our program that we had anticipated.

And you used pieces of it. You can only get so much done. That is video sitting at your desk compared to being in person. So what we did is broke it into three parts and divided the typical conference into three parts of the year. The first one was during the meeting itself, but just not at the Drake and then play that out through the year.

So I think our sponsors really supported us as well to say, just go at it and continue to use our funds to produce. Meeting and do it virtual. So we did all of that for 2020. We did the whole program. 

Griffin Jones: [00:14:17] What's it going to be like this year in 2021? 

Dr. Angie Beltsos: [00:14:19] This year, the date of our usual program that like you said, it's usually in June, we are going to do virtual, just the board review course, which is going to be amazing. It'll be June 11th through the 13th, all virtual, but this is going to help people that are students, medical students, residents, but particularly the fellows who are preparing to become board certified. And during that program, we'll be diving really deep into the science and our real program for the Midwest Reproductive Symposium International 2021.

We'll be in person September 21st through the 24th, we will have also a virtual component to it. So it will be hybrid. And we're really excited about that as well. 

Griffin Jones: [00:15:10] What do you think. Should be virtual as we move beyond COVID, as we move beyond like the, that forced shutdowns. Right? What should be virtual moving forward?

2022 and beyond. And what should be in-person 2022 and beyond. 

Dr. Angie Beltsos: [00:15:29] You know that's a great question. We were talking with some of our brilliant board members. And like you said, are what started as our small group has now turned into, really amazing people that are part of our organization. And we talked that we wanted international, component with Scott Nelson.

He's our international board member, who is at the University of Glasgow in Scotland, but we have board members from coast to coast and. What we realize is that in different locations? And different time zones in private practice and academics. You have to now have this virtual component because people may not be able to attend, but they want to hear key lectures.

So there's going to be a couple of different options. One are just being able to get like a little appetizer, some key lectures. And then there's also the ability to watch the whole thing from around the world. And we expect that we'll have people from different continents participating now. And I think that's, what's really cool about it, but like everything else, there's nothing, that people don't enjoy more than being able to see each other.

Now, having some, coffee together, cocktails, you know, and like you said, building up relationships in person. So that's also going to be available. And I think that hybrid approach will be what we do with our patients. It's what you're going to see in business going forward, as well as,  these meetings.

Griffin Jones: [00:17:06] Do you ever see the hybrid programming shifting so that certain programs are all digital and then certain programs are all in-person. 

Dr. Angie Beltsos: [00:17:19] I think what there is in life, there is about 80, 75, 80% that you can communicate through an entire digital approach. And that includes some of the relationships we have and then the water cooler kind of effect, or the in-person contact will be missed if a hundred percent of it is done digitally.

So I think you can get a lot accomplished, with the video conferencing, but I think. That doing everything a hundred percent video, you will also miss some important things that happen when the cameras shut off. 

Griffin Jones: [00:18:05] I think so too. I wrote an article about this, right? As everything was shutting down, I wrote it in March, 2020.

It was like soon as they canceled PCRS, I fired it out. And it was an article about what I think should be in person. What I think should be video because our company has been remote since you've known me. We've always been remote, but I will tell you. It hurt even in, COVID not being able to get together, even though my project managers in Memphis, my operations managers in Nashville, my digital strategist is in Colorado, a account managers in Miami everyone's everywhere, but we still normally get together a couple of days a year.

In-person to do the stuff that we need to do in person, which is the major long vision strategy and the personal bonding, all of the execution we can do over video. So I wrote in that article, this is what I think should be in person. This is what I think should be done. Video. I think a lot of the speaker stuff in the future can be done via video.

I think the in-person workshopping and and the networking, is what the in-person meetings have to offer. So why don't we just start building those programs,  around that way? What do you expect to see this year in 2021, knowing that it's people have kind of gotten the habit of all, it can do it from zoom, but they've also, they're also kind of starving though.

So what do you expect to see this?

Dr. Angie Beltsos: [00:19:36] Well, we hope that some people will. Be able to, come from around the world and participate via zoom and via video conferencing. So I'm very excited about that. And I think that some of the key lectures you can present that. On a screen. But I think the dialogue that happens back and forth and seeing the audience in person is,  is also priceless.

We do workshops, which I think is also unique where we break the whole audience into groups that dialogue into kind of a small group, a round table kind of discussion on different topics. And I think that would be you know, better done. I think those kinds of things could be better done in person. 

Griffin Jones: [00:20:27] So those types of things, I see that as the future of,  in-person events.

And I sometimes think that events like yours are better poised than some of the larger ones for that reason, because it's kind of built for that. It's built for that in person, that in-person. Type of relationship building and yeah, I, you know, like I said I'm, I'm a hundred percent pro-zoom pro doing anything that can be done electronically.

Electronically, Fertility Bridge has never had a home office that said, I also don't think I ever would have built the relationships that I did had it not been getting to meet in person, even if I, sometimes there's lots of relationships that I have. Digitally first, but then I meet them in Chicago. I meet them at MRS and that puts a certain icing on the cake that is irreplaceable. 

Dr. Angie Beltsos: [00:21:19] Irreplaceable.

There's a great book called The Art of Gathering by Priya Parker. That was a gift from Hannah Johnson and it's how we meet and why it matters. It's a great book for those of you listening, who do care about meetings and how we meet and whether it's your family, whether it's your business, whether it's a big conference, it really is important to consider the elements that allow it to be successful and how you want that flavor.

To be what you want to accomplish. And I really appreciate you, Griffin inviting me to talk about, our meeting, but what the elements are. I think that intimacy is very important and people start to become more open in certain size groups , and numbers. So there are certain things we accomplish in the big symposium, and there are things that you get out of it by being able to speak and dialogue with your colleagues.

 Howard Jones God rest, his soul had, said some really important things to me about the MRSI meeting. And for those listening, he was one of the fathers of IVF in the United States. He had the 13th IVF baby, born, in the world, but he. He was saying that when you have a meeting, make sure that most of the meeting is your Q &A and talking, let the audience talk to each other.

Don't spit out all these lectures and, you know, we invite these brilliant people to give lectures with 75 slides in 20 minutes, but they really, you know, that, that idea of throwing out the topic, the latest. It's points of what's relevant and then let people talk about it. And that's when you really take things home.

Griffin Jones: [00:23:18] And do you have the opportunity to do that? Especially as a breakout speaker at MRS people always come up to me after MRS. Specifically. And it's great too, because if I need to talk to one person because they got to me first, say, Hey, I can see you at the cocktail hour later. They don't just, they can't just, they don't just lose me in the ether.

And that's. Maybe that's the Je Ne Sais Quoi of MRS 'cause I'm thinking I love PCRS. I love CFAS. And those two are smaller meetings that are very collegial and I really liked them. And I'm thinking, what is the Je Ne Sais Quoi of MRS? And I think it's partly Chicago. I think it's partly you Angie. And I think it is, multi-disciplinary focus, which isn't is true for the other meetings, meeting the size, meeting the social events. And I was talking with one of my employees today who's really advancing in their career. And I said to them, Part of being a senior person is even when you're in your role, you know, how you play into the rest of the picture.

So I think even if you're a mental health professional, and that's your thing, knowing what the doctors and scientists are up to right now is really important. Even if you're a doctor, knowing what the nurses are up to right now is really important. Even if you're a nursing manager, knowing what the business minds are up to right now is really important.

So I hope that you. Continue that streak at MRS as it evolves. 

Dr. Angie Beltsos: [00:24:48] Well, I appreciate that. And I think,  the other piece of all this, as we try to play a lot of music during our meeting before, during and after, and, when we talk about , you know, what makes things attractive is that people learn really well.

If you activate both sides of the brain, the right and left, and there's a lot of scientific studies, how important music is. So, you know, The music, in the very beginning, between every speaker and it activates that side of that art side of the brain the other , relaxing side. But then you throw in some hardcore science and it's supposed to really help with, feeling really good about things and having fun, but also learning.

  Griffin Jones: [00:27:50] So now that it's established and now that you also have an established practice group, what do you think you get out of it? 

Dr. Angie Beltsos: [00:28:00] This has it's a really great personal question for me. It changed my whole stratosphere. My the course of my, my career. It changed the whole direction of who I am and how I practice medicine, who I talk to in a moment I wasn't doing, you know, I was just. One of a new grad of doctors in the country. And suddenly I was friends with the thought leaders. And from there you get invited to give a lecture in Canada and then you meet, go end up in Europe. And in Europe I met people from Australia, the president of the Australian fertility, and then all of a sudden you're in, I was in.

Australia giving lectures and from Australia met someone and I was in China. So I literally went from being this little. Chicago doctor organizing a meeting and through it, I became, I made friends with people all over the world. People that showed me the backside of the kitchen. You know, you go to these great speakers, the, and they take you home and they invite you into their world and they teach you how to run your business and things to do and mistakes they made.

So. This out of all the things in my career, as far as fertility goes, this hands down changed the whole course of my life. 

Griffin Jones: [00:29:31] It's funny because you're talking about the history of you getting plugged into other people through this. My experience is you plugging in other people through this, like myself included, but I think of, you know, not to blow up your spot, Angie, but you are better at your fair share of you get more of your fair share of younger docs in recruitment than many people do.

And I think part of the reason for that is. Accessibility.  And I think  MRSI just a megaphone of accessibility. 

Dr. Angie Beltsos: [00:30:06] Yeah. It's been a, it's been a gift. I've been very blessed to have been given this opportunity to fund. I mean, the money that. Came through to, to organize, had to be properly managed. And through that you create a, hopefully a platform and the younger people that participated as fellows have become friends of mine.

And some of them  have joined Vios and some have been. You know, colleagues in the country and in the city and it's been awesome. So I think that was correct to that. We've had a chance to make new friends in a variety of age groups, not just the older , genre of thought leaders and people that invented what we do, including Louise Brown, the product of, thought leaders, but also the younger group.

We've become,  had that opportunity to get to know. So you're right. It's been a gift. 

Griffin Jones: [00:31:10] Well, let's end this thread of cultural relevance for a second, because I'm obsessed with it. I stay up thinking about how I'm going to be culturally relevant when I'm 88 years old, it's something that I really obsessed with.

It's like longevity meets sustainability meets just something I intrinsically really enjoy. And I see some of the advantages playing out for you. And I think that might be a gateway drug for the people that might not just geek out on it as much as I do, but if they can see yeah, you are the perfect case in point.

So, but if they can see the tangible benefits of what you've done, I think so many people are having a hard time recruiting doctors right now, recruiting younger staff and. One of the ways that you've been able to do that. As you give fellows a platform, you, they always, they know that they can call you.

They know who you are. That's really important. They see you. Content. And so maybe we can extend some of this to other people. They're not going to go off and start their own meeting because it's way too much fricking work. But even if they were a chair for one of your programs, even if they were a speaker at ASRM, that's more accessibility.

So maybe we could just talk about how that accessibility to the younger generation helps you stay relevant to them as they start to take over the reins. 

Dr. Angie Beltsos: [00:32:36] Yeah, I think that's such a fascinating topic of cultural relevance. You know, it's like a moment ago, sick was kind of a bad thing, but you know, that is so sick really.

Is that a good thing or a bad thing? Oh, I guess it's a really cool thing. And in the moment you become, you know, all of a sudden the words people use and the way that they approach life, but you're, You've got to be a little willing to always change. And human nature is the opposite of that. Don't get stuck in, you know, your old ways.

Try to learn, try to be a chair and take that stuff home and be a little uncomfortable. I think that's really important. Remember that when we lead the group, That we have to have humility and we have to be part of the group and let the group also have opinions and decision-making and feel valued and appreciated.

And it is a, very delicate balance. Isn't it. 

Griffin Jones: [00:33:43] Tell me more about that balance. What makes it so delicate? 

Dr. Angie Beltsos: [00:33:48] Because as the. Leader of an organization. You may be the medical director, some of the audience members, they may be trying to hire or keep, you know, these young, vibrant physicians. And they're going to be people that come and go for a variety of reasons, but we have to look in the mirror.

We have to be accessible. We have to be, a teacher and a student. That dichotomy has to exist. You have to be a leader and you have to be allow the others to lead you. And so there's this, this balancing act and your people in your life will be your witness, good, bad, or ugly. And they're going to talk and social media today.

It's just like our customers. They're talking about us. They're  explaining, you know, the day to day activity. And so you have to listen to people's dreams and their aspirations and support them. And we're not perfect at it. God knows. There, there is intent there, and you have to figure out what you believe in , and how you're going to do this.

You know, the MRS is a charity to me and Nelson Mandela says the most powerful way to change the world is education. And so many people helped us get to where we're at and I cannot repay them. You know, the people that believed in me and gave me a chance. Those, I can't give them money. I can't give them something to help them do what they did for me. The only thing I can do is turn and give forward, right? So we give to the next generation, the next people and the people that are attending to, provide the best care to people that want to have a family. If you just go back to your mission of why do you exist?

Why do you do what you do?  Trying to create a team around you and that cultural relevance is,  is always to be open minded, I think, and open your heart and your mind be accessible. And I think. Wanting to listen and be friends with people from all different walks of life. 

Griffin Jones: [00:36:04] I'm going to push back on one thing you said, of course, like I'm just like riding the lightning of 90% and I choose the one thing that I'm gonna push back on.

But one thing, the one thing that you said. Is that I can't pay them back. And for some of them, that's probably true. Maybe some of them are gone or some of them, you just won't have something to offer that they need in the rest of their careers or lives. But I think many of them, you are in a position to pay back that those that helped you get to where you are now.

Some of them may be being put out to pasture. Oh, we've heard from him. We got it. We don't need his ideas anymore. And you're in a position now to say, no, I really remember this person helping me out. I'm going to give them a platform. I'm going to help them maintain their cultural relevance because they helped me and they are still relevant to me.

So I see that happening and I see that. I remember the people that put me on in the beginning. And now that my cohort is, and we're not in our early twenties anymore. Angie, now that we're in our mid thirties, late thirties, and we're starting to be the executives and at the very least the director level and the owners of companies, the people that it's not just returning a favor either.

It's hey, I learned a lot from this person and I think they still have that value to teach. I think you can repay some of them. 

Dr. Angie Beltsos: [00:37:29] Yep. You know, I think about, the opportunities that we got at all levels. I remember. The person who gave me a scholarship to college, you know, the, like you said being thoughtful about that and reciprocating can be very powerful all the way to someone who spoke at my meeting and gave me, knowledge that helped me hopefully get one more person pregnant, that I tried something new and different and being grateful to them and honoring them is , is really important. 

Griffin Jones: [00:38:06] This is so meta because the topic that I'm speaking about at MRS this year is how to manage millennials and gen Z in the workforce in so Meta, because , at least some of what I've learned has been through interactions at MRS. And you're talking about this balance of leadership and following

I'm not a new agey person that says, oh, just listen and do whatever they say no, at the end of the day leaders lead, but leaders. Based on information that they see and they get that information by asking and interacting MRS is an awesome place to do it. And a good exercise that I do every year is it started with your kids.

Angie 1: because I just think your kids and their friends are really well raised. And anyone that wants to talk trash on how kids are raised the other day. Listen, most of the time, I might even [00:39:00] agree with them, but there's always examples to the contrary. And that's your kids and their friends and looking people in the eye taking.

 Ownership of whatever they're supposed to be doing there. You put them to work there at the conference and they're doing work and I love taking your kids and their friends and whoever the interns are out to lunch every year. That's a tradition. I started a couple years ago and. If they're there, I'm going to do it again.

Well, I enjoy it too though. Angie, like I, I just watched them. I watched what they go out. Like I watch what they go out on the dance floor too, versus what we got on the dance floor to, I watch how they interact with each other. I watch my own, my one rule for them when I take them out, is I, and they all.

Cause you and Nikki tell them before I've even taking them out. I say, what's the rule. They said, no cell phones at the table. I go. Right. And so, so then I just get to talk to them and, and see what they're interested. And the reason why I'm saying all of this in regard to your lesson about leadership and following is because iIf I want to be able to lead this cohort, when they're in the workforce in eight years, I need to know their language and I'm not just going to learn their language. If I start the moment that I need to learn the vocabulary, if I'm a bit invested in how they're growing up and how they're finishing high school, going through college, entering the workforce, picking up the things that they're doing along the way, I'm going to be able to speak their language.

A lot more fluently and be able to tell them no, shut up young person and listen in the way that they'll actually understand and doesn't come across like that. And a lot of that I get from MRS. 

Dr. Angie Beltsos: [00:40:43] Well, thank you. That's a funny part and a funny story I had, you know, these were always so careful we get as a charity.

Basically sponsorship and donations to try to run the meeting. And people don't want to go to kind of a small, simple hotel cause they want to be able to enjoy the space, but that all takes money. So I called one of the meeting organizers at a company and they said, I said, how much would it cost for someone to come and check people in and hand them their badge?

And they were like, that's $45,000 and I go, you gotta be kidding me. I was like, all right, kids get dressed. And I thought, you know, what a great way to have for a high school student. To have some exposure to a professional event, be responsible for the happy customer and the customer. That's being a little difficult.

And one of them. You know, they still quote today was one of the doctors that said, this does not say doctor on the top of it can make me a new badge. And I was like, yep, this is customer service. You know, people want to make sure that they're honored and they're whatever. And they had, and I want you to greet people and welcome them.

And so we ended up, Having the high school interns have their exposure. A lot of them put them on college applications and they said when they were applying, they used it as some of the things that they wrote about their experiences. But also for us, it allowed us to, have some young people be very kind and welcoming and hang out with Griffin Jones, but also was a lot less expensive than the, the company that wanted a big chunk of change to greet people. So. 

Griffin Jones: [00:42:38] Well, I'm glad that economic way pushed that forward because they have a lot to learn, but there's also a lot that we can learn from them. That's one of the multi-generational values of, I encourage other people to do it as well. You have to be able to speak the language, or you're going to get put out to pasture? There's another episode that I did with this. Almost on this theme with Hannah Johnson, who I'm speaking with at MRS. This year on millennials and gen Z, but it's the flip side of the coin too. Dr. Beltsos how do you want to conclude on MRS and collegiality and, or multi-generational collegiality in the field and tying that all together.

I'll let you put the bow on that with final thoughts. 

Dr. Angie Beltsos: [00:43:28] Thank you for inviting me to speak at your podcast. It's always an honor and a privilege. And in that same context, I think the Midwest Reproductive Symposium International that I at the end is supposed to cross boundaries.  It's supposed to take us that are wanting to be taught from the learned to be open to different ages, approaching similar topics.

Different perspectives. So we hope that the audience that is listening will bring themselves and their friends and their colleagues to our meeting. Not only this year, hopefully in 2021, but in the years to come. And that the meeting allows us to grow, stand on the shoulders of giants. Be a little uncomfortable with taking some of the stuff home and trying something new and continuing to be open to growing.

And I always ask people no matter where, how old they are is what do you want to be when you grow up? You know, as , we look to the future and, I think. That spirit is embodied in MRSI, so with that, I appreciate again, the opportunity to be with you to be,  motivated and inspired. 

Griffin Jones: [00:44:59] Angie, I'll see you at MRS, in September Inside Reproductive Health listeners. We hope to see you at MRSI in September. We'll have a link in the show notes, and we'll send that out with the email Dr. Angeline Beltsos thank you very much for coming back on to Inside Reproductive Health. 

Dr. Angie Beltsos: [00:45:15] Thank you.

Breaking Through the REI Bottleneck with APPs

Sometimes it’s the REI that holds back the growth of a clinic because he/she is doing tasks that could be delegated. It’s our job at Fertility Bridge to help you bring new patients through the doors of the clinic and it’s your job to convert as many of those patients to treatment as needed. In this week’s episode of Inside Reproductive Health, Griffin chats with Tamara Tobias on her perspective on the role the APP plays in reducing the REI bottleneck.  

Tamara Tobias is a nurse practitioner supervisor at Seattle Reproductive Medicine with over 24 years of experience. She is active in ASRM, currently serving on the Membership Committee. She helped develop the REI nurse certificate and basic courses available through ASRM and is a recipient of the ASRM Service Milestone Award. She is also an active leader in her local fertility community and publisher of Fertility Walk

Topics covered in this episode include: 

• What your APPs should be doing vs the REI

• How the REI could increase productivity by only doing follow-up appointments

• What to do to have recruiting advantages

• Training APPs 

Connect with Tamara: 

LinkedIn: https://www.linkedin.com/in/tamara-tobias-0752bb30/

To learn more about our Goal and Competitive Diagnostic, visit us at FertilityBridge.com

---

Transcript

Griffin Jones: [00:01:01]  Breaking through the REI bottleneck with advanced providers. That's the topic that we're going to delve into on today's Inside Reproductive Health. To help me with that. I've got Tamara Tobias. You might know Tamara because she's a nurse practitioner supervisor at Seattle reproductive medicine over 24 years of experience.

And she's been very active in ASRM before I get into today's show. Today's shout-out goes to the NPG, the nurse professional group, the subgroup within ASRM, who does a lot of good programming. That I think is relevant to today's topic. And because of that, I wanted to give them a shout-out. In today's episode with Tamara, we talk about the role of the physician extender or advanced practice provider.

If you're hip to the current nomenclature, how that started off their role, maybe 15, 20 years ago, how it's changed radically in the last five years, but really in the last year and how they are part of the key to us, being able to see more new patients as a field, move more people to treatment that need it, and aren't stuck in the REI bottleneck.

And so we walk that line together. What those APPs should be doing and what really needs to be in the purview of the REI because that's a sub-specialty for a reason And so Tamara gives you a lot of food for thought In this episode if as a clinician you have a different point of view You're welcome to come on the show I'll tell you every time that I do a show that butts up with something that's clinical operations My job is to get as many people to treatment as needed And I could keep bringing new patients to clinics all over North America But to the extent that we hit this bottleneck there's gotta be other solutions which is why I'm interested in unpacking solutions like these if you have a different point of view, you're welcome on the show. If not sit back and listen to the point of view that Tamara gives us today. Ms. Tobias Tamara welcome to Inside Reproductive Health. 

Tamara Tobias: [00:03:01] Thank you. Thank you, Griffin, for having me excited to be here. 

Griffin Jones: [00:03:04] I'm excited to have you, because I'm looking forward to going down a topic that I think is inevitable.

We were both talking about how some clinics have been so busy recently. And so I think the role of the physician extender or advanced provider, whichever nomenclature people use in their clinic is going to be getting more and more involved in the coming years. And you being a nurse practitioner that's been in this field for a while.

I would love to hear your perspective of just the role of the nurse practitioner. And if you can speak to it also, the physician assistant was when you started and then how it has changed. If that is in fact, the case. 

Tamara Tobias: [00:03:47] Yes, I'd be happy to. So when I started, back in 2004, they really weren't sure what to do with the nurse practitioner.

And so I was actually hired on as the third party, program coordinator to just bring up the third party. I think that's how a lot of nurse practitioners started as people thought, okay, can you develop our third-party programs? And really it has evolved. So much in these last years where we're really utilizing the nurse practitioners skills to its full extent.

And so now by doing procedures and ultrasounds and seeing patients, and really I'm speaking of nurse practitioners and physician assistants, and I think the best term to utilize, which is more, the term everybody's using across the country now is. APP, which is advanced practice providers. So that includes your physician assistants, your nurse practitioners, and your nurse midwives,  in reproductive medicine there right now that the trend, there are more nurse practitioners than PAs.

We did a survey with the nurses professional group. About two years ago. And with that, we had about 30 respondents and there were 23 nurse practitioners at that time and about six PAs and one nurse midwife.  But I see those numbers definitely growing. 

Griffin Jones: [00:05:07] It seems to be the case that nurse practitioners outnumber PAs, at least from just our clients and people that we work with.

So it started off with a third party role and you still see, I see a lot of NPs in that role, in fact some clinics that are bringing on NPS for the first time. I still having them do that first. That's like the first thing that there doing. So how did it grow after that then what happened? 

Tamara Tobias: [00:05:31] You have to push, they have to push. Is there a way to show them that they can do? And,  that was me being a little bug in their ear is like, I, yes, I can see these donors and bring on the third party, but I can see your recipients and I can do their ultrasounds and I can do that donor ultrasounds. And then they can see that if you're performing those well and you're doing a good job at ultrasounds that it opens up to more like, oh, sure Maybe you could do more ultrasounds follicular dynamics. And then it even evolves to doing OB scans and then it becomes procedures. I think if you're working third party, they think, well, maybe you're doing ultrasounds. Now you can do a sailing on a histogram, maybe on my recipient will you do that salient sonar histogram was using an ultrasound, but then you could push a little bit more and say, well, I can do not only recipients. I could do your regular IVF patients. And now I can do office hysteroscopy and HSGs and hysterosalpingogram. And so you just, it's just keep raising the bar because you are practicing within your scope.

And we'll talk a little bit more about scope and different states, but I think it's just letting those physicians realize , The training and the background that you have and how you can apply those skills. 

Griffin Jones: [00:06:46] So let's talk a little bit about that scope. How do we know that a nurse practitioner or a physician assistant is qualified to do those things that you said?

Tamara Tobias: [00:06:56] Yes. So if you look at our training, if you look at federal law, simply states that nurse practitioner needs to follow the training and the education based on your state. And that's where it gets tricky because every state has a different scope of practice. And for example, in Washington, we have a very broad scope of practice.

So in Washington we've really, I really can provide care to my full education. So that's diagnosis, that's management, prescribing, and prescribing medications. That's all within the scope of practice. That's Washington state. Now you have other states, for example Michigan, unfortunately, nurse practitioners there they have to operate under their registered nursing license and the only way they can apply for their skills such as, procedures or ultrasounds under supervision of a physician. But I think having said that, I think in reproductive medicine, we're so specialized that even if we're working in a restricted state and every state is so different, even if we're working in a restricted state, I think in reproductive medicine almost all of us nurse practitioners, or APPs, we are working at collaborating with the physician. And so if we're collaborating with a physician, then we should be able to apply all of those skills and be able to provide all of those services. 

Griffin Jones: [00:08:20] So it really really depends on the state medical board. That's who sets the scope for the APPs?

Tamara Tobias: [00:08:26] It's the state it's both the state medical board and the board, the nursing board of that state and its legislation in that state. 

So you're in Washington state and maybe you can't speak to Canada. It's okay. If you don't have any cursory knowledge of that, but we have some Canadian listeners. Do you know any, anything about the regulations in Canada with regard to APPs?

Not a lot. I do know there was an APP in Canada. She's fantastic. She's reached out to me. I'm just reaching out to find out what I do in my practice and such to see if she can start doing those things in , her office. And so I'm always happy to share. I shared with her, my orientation checklist that I have of every heck includes all of not only procedures, but as well as consults that we do.

And I shared that with her to see if she can start doing that in Canada. 

Griffin Jones: [00:09:19] If we have any Canadian APPs that are listening and they know a little bit about the legislation and the regulations in different provinces. Feel free to email me. We'll have you on the show. We'll do an entire episode about APPs in Canada.

One thing you mentioned infertilityTamara was procedures and talk a little bit about that are we talking IUI, what else are we talking about when you say that APPs? 

Tamara Tobias: [00:09:42] Yeah, Procedures, so ultrasounds and ultrasounds can be ultrasound for follicle, your IVF, as well as OB scans IUI, and the  endometrial biopsies uterine evaluations and the most of the uterine valuations I do our office hysteroscopies,  but we also provide HSGs as well as SIS is the salients on a histogram.  We do biopsies for ERA when we're looking at that and our mutual scratches, which is outdated now, but we can do that a lot of physical exams on all your third parties.

And then I would say the other thing I do a lot is problem visits. So those that are calling in, they have pelvic pain or they have cyst or they're bleeding, somebody that needs to be seen same day. And so that's a lot of  what a day-to-day is. 

Griffin Jones: [00:10:30] I want to come back to the problem visits, because that ties into another sub topic that I want to address with you.

 One of the things that's involved with procedures that I hear people talk about is retrievals for IVF. Can an advanced provider do that? 

Tamara Tobias: [00:10:44] That is a surgery. And so advanced provider, I do not know of any in the United States that would do that. Not necessarily in our scope because it is a surgical procedure.

So again, within the scope of our nursing background, our focus was really,  wellness and education. We can diagnose and treat and do some procedures, but not necessarily a surgical procedure. Now I can't speak on that with a physician assistant. Because they may there's physician assistants who do some surgical procedures or assisting.

And so that could be a possibility. 

Griffin Jones: [00:11:21] Okay. That's an interesting distinction. Let's go back to the problem. Patients. Everybody loves the problem patients and it seems like, oh great. I'm an advanced provider. I'm the one that gets to deal with these problem calls a problem visits and what I'm wondering is how does it tie into one thing that physicians really concerned about, which is what does the physician need to do?

[00:11:48] What does the physician really need to be present for? And some would say, well, absolutely. The high-touch cases are the ones that the REI absolutely needs to be involved with. So. What's the  purview with problem visits. When there's a NP, that's perfectly qualified to take care of at least some of them, 

Tamara Tobias: I think we're all working together.

And so when they, when these patients come in with problems that it could be hyperstimulation, I don't see as much as that anymore. I used to, unfortunately. So it'd be hyperstimulation it may be an ectopic pregnancy. I just had a molar pregnancy. So I think the key point is. The physician or they are may be in a zoom consult.

Right. And their schedule is packed and I might have a 15 minute opening in my schedule. So those patients come on, I'm doing that initial assessment. I'm doing that screening. I'm doing some blood work. I'm seeing what's happening. I'm doing the ultrasound, but I'm then collaborating with the physician. So I think it's important. For all APPs and we all do this. We work very collaboratively with our physician and follow up appropriately. So depending on what I see, I may have to pull that physician in. Maybe during that consult and get in another opinion, or if I have a field demise, I might not. I want another set of eyes. I may say I'm so sorry.

I don't see a heartbeat, but I, that is such an emotionally charged moment that I definitely want to pull somebody in and just get another set of eyes. And so I'll do that. And so I, that's why I feel that even those problems, they're hard. They're very difficult. Cause they're just added on your schedule. But you're not out there flying solo. You're definitely collaborating. 

Griffin Jones: [00:13:28] Collaborating, but is the collaboration triaged is the app essentially doing triage on these problems visits and then bringing the they're the gatekeeper that brings the REI in when there's the most complicated cases. 

Tamara Tobias: [00:13:40] Yeah. Yeah. Unless we can manage it.  But I would definitely consult, like, if I feel like this is what it is, if it is an ectopic pregnancy, I'm not going to be the one doing the surgery on that ectopic pregnancy. So I think it's important.  To absolutely bring them in. 

Griffin Jones: [00:13:56] Well, I'm thinking from the REI, point of view, should they be having, if they can have the ability to hire APPs, should they be having APPs do the problem visits to triage those cases?

And then the REI comes in on those cases that the advanced provider brings them into. 

Tamara Tobias: [00:14:15] Sure. I do think  that the problem visits are going to be the most challenging. And so those are, you're going to want your more experienced APP to be managing. So it may not be until a couple of years down the road where that physician feels very comfortable knowing that APP is more experienced and better able to triage co-manage those patients.

I think the day to day, things like that procedures the routine ultrasounds. Absolutely. We can do those, but I think it does come down until more training and more, more senior.

Griffin Jones: [00:14:54] Well, let's talk about that training and how one gets to that level of seniority, because the entire reason why you and I are talking about this topic Tamara, why is a marketer so fricking interested in nursing operations here?

It's because my job is to get a million people through IVF treatment in the United States that needed versus the 200, 250,000 that are getting it right now. The bottleneck right now is the clinic. The bottleneck is the clinic, the lab, the doctor, and I could bring people. Way more patients, but we're still hitting a wall.

And so anything that starts to get more access that we can treat more patients with. That's what I need to learn about. So you mentioned that. That level of triage and seniority comes after a couple of years, what training needs to happen in order for them to get that senior level of experience?

Tamara Tobias: [00:15:47] Yes 

you're absolutely right when we both talk about marketing because I think about that and, bulk of revenue is from IVF, right? For reproductive practices. It's the IVF, it's the surgery. And that does need to be managed by the RE. But utilizing a nurse practitioner or an APP, I think is a win-win.

If you utilize them for procedures, you're utilizing that for procedures, for ultrasound, that's going to free up your REs time. And so that RE can be doing more of the IVF consults and then your advanced practice providers can be doing more of the procedures and the ultrasounds. And even with the ultrasounds, I think the benefit there is that the APP.

As a nurse practitioner can be helping talking about their plan. We can talk about their next steps can diagnose if they, perhaps they have a yeast infection and it saves nursing calls because they don't have that. The nurses don't have to do as many callbacks if the APP sees that patient.  So training can be tricking. It depends on their background. So it really depends if I have a new nurse practitioner who first was an RE fertility nurse. And I have a lot of those actually in our practice had five of them that were fertility nurses first. And then they went on to go to school to get their master's degree in a nurse practitioner.

So they have a lot of that RE experience. They're not going to take us long to train. But it is. It's not as straightforward and there's not an organized program out there. And I do my best. I developed a program in our practices because of the number of APPs we have, but I think it's important to look at ASRM as a resource, an excellent resource utilizing the ASRM certificate course.

I have them do a lot of independent study, a lot of independent study reading F & S for fertility sterility. If it's a nurse practitioner in a small practice where it's just one doc, if there's going to be a lot of one-on-one training and observing and learning those procedures. And until that physician feels comfortable, APP can do those on her own or he or she on their own so it's time.  

Griffin Jones: [00:17:55] If you could build your master course, if you could create it beyond the, and you've done a lot with your own practicing, I think we've also done work with , NPG and other groups. If you could create this master course, what would the table of contents be for to bring other advanced providers up to the level that REI will feel comfortable turning the reins over to them? 

Tamara Tobias: [00:18:18] So one is the basic understanding. So you're going to have a huge didactic component going through all the components of infertility and then the second is going to be procedure. And I think there's a lot of really good online tools now. For example, ultrasound, how do you train somebody to do an ultrasound?

And there's a lot of good there's even YouTube videos. And I have a list of good, I feel quality YouTube videos that I have my nurse practitioners watch. Unfortunately, there's not a lot of in-person courses right now, so you're really relying online and in the office training, Yeah. And I also, I would, I have a master's so  I think that there's two components.

I think there's a lot of procedures to the APPs. And then I think there's a lot of that infertility diagnosis and management. That's more the didactic and that's where I lead to an APPs. Also see a new patient and maybe we can chat about new patients and how they can help out with the practice as well.

Griffin Jones: [00:21:55] Let's do that because we really, we need to solve some of the new patient bottleneck that's happening right now. And I spoke with one of our clients today and said is, was that something you'd feel comfortable with letting, an NPC, the patients on the first visit? And he said, no. And so let's have you make, or at least show us the path.

For how it, it could be the alternative. 

Tamara Tobias: [00:22:24] I absolutely think there's a combination there that can definitely happen. And so I yeah I also have heard some feedback from perhaps like an OBGYN I say, well, I'm referring to an RE, I'm referring to the specialist,. Why should they why should I refer them to you then just to see that APP And I would say two things to that I would say one is that we are working together with the RE So we are collaboratively working together. And I really think that's a win-win for that patient because that patient is not, is now getting. Two providers instead of one provider. And I would say that APP, I would also encourage that APP to go out to the OBGYN, to introduce themselves, to do lunch and learns, to let them know that I've been doing this extra training.

I am specialized in this and I'm working together with that physician and we are a team. And so I think that can be a really a win-win, Other ways I see it as nurse practitioners or APPs are focuses on wellness. And I think a lot of patients, especially infertility, patients really want a holistic approach because they're out there, they're out there seeing natural paths.

They're seeing acupuncture, they're trying herbs. They're doing all these things on their own before they even see us. So I think an APP is a nice natural fit. I've seen different models and it depends on how that practice operates. And so I've seen models where the nurse practitioner does the initial intake on all new patients.

So they'll do the complete history, physical, not doing so many physicals right now but do the complete  history start the workup. And then the follow-up council has done by the RE and that saves that RE a lot of time because a lot of the front work has been done already. 

Griffin Jones: [00:24:17] Those patients also convert to treatment more readily, if the REI is only going to be at one of the visits, it's better to be the follow-up.

I can't tell people from a clinical outcome one way or the other, what they should be doing. I'm just saying that people that are in that group convert to treatment more readily. 

So one of the things that you talked about with regard to physician assistants and NPs being involved in this process is how they're introduced to referring providers.

And that dynamic that you mentioned about referring to providers is one of the big reasons that people are nervous about having, not just APPs, but also other. Physicians, like if they hire a new doc, we're worried about pushing some of their waitlists to that doc so that they can get busier faster because it's like, well, Dr. Smith referred them to me and we have that relationship. And I think that's such a mistake. And so I want to talk a little bit more about that and I want to share just. A bit about how we do it in my own firm. And I know it's not the same thing as MD referrals, but people hear me on the podcast. They see me at speaking at PCRS with the red pants or around with my haircut.

And so it's like they're buying group, but the first time that they're speaking with us, it's my, it's not just myself. It's my director of client success, who ultimately is the account manager. And so if. If they are going to move forward, they're talking with her from the very beginning and they know that once they're on the other side of this, it's like, Griffin's not the one handling the account.

It's this other person that came in real early, even before we decided we were definitely gonna work together. And if we decide like, Okay. Yeah. We want to talk about this in more detail. Then we bring in our project manager. And so they're even one level deeper before we ever like ink the paper that, yes, this is what we're going to do together.

So that transition for us has been super smooth. It ties into what you were talking about with bringing the advanced provider along. What else can you do to. Help build that relationship with referring providers and we have an referring provider strategy, but I'm asking you in such a way that I want to know.

When did you maybe I feel like a third wheel and or how can you make sure that the advanced provider that you're promoting doesn't just feel like an add-on? 

Tamara Tobias: [00:26:51] Yes. Yes. Got to get out there. I think if you're new to a new APP to a practice, it's getting out to the OBGYN.  We utilize our marketing people and they're wonderful.

They get these lunch and learns, set up. You can do my webinars. I think that's important to just get that face, let them get to know you and know that you're working alongside that. RE , Another way. So, and then your website, a website is another really important tool because I find the biggest mistakes, and this is my personal opinion, but if you go to a website and it lists our providers, some practices, they only list the REs.

And they don't even show the faces or lists the APPs or who are really working in co-managing and helping these patients. And in our practice, we don't list. Who's they're in alphabetical order. And this is your team. This is your team. Who's working with you. And it's not, there's not this hierarchy.

And that's what I love. I love about our practice. And I think that's an important message for marketing is you're a team. It's not one for over another. And you're providing the service together. 

Griffin Jones: [00:28:04] When we do our episode on physician referring physician strategy, which I think is coming out next month, I'm going to make sure that we give a special shout-out to the APPs for this exact reason.

So, okay. So let's say we've assuaged that concern. What does the REI still need to be doing? Because Tamara I'm thinking of my own primary care physician. I don't have a primary care physician. I of course do at the general practice that I go to. I've never once seen it, my provider is the nurse practitioner and has been since I was 18 years old.

And so I just view that person as my provider. People can say, well, fertility is different. REI is different and indeed it is. So what does the REI really need to do still? Even when we have brought in our APPs, 

Tamara Tobias: [00:29:02] Absolutely. So we talked about different models. And so one model, like I mentioned before is sometimes the APP does the initial assessment, the initial workup.

And then the follow-up is with the RE. Another model is looking at what appointments are appropriate, perhaps for an APP. So for example, look at donor sperm patients, same-sex couples. They go to an REI practice. They're not infertile. Right. They may be a little, they may be subfertile because of their using frozen sperm, but they're not infertile.

And so those are completely appropriate patient population that the APP can see, can manage. And in our practice, we sort of have a protocol, like if they're not pregnant after three attempts of this or that, then they're going to have a follow-up with one of the physicians. And so we can get that initial part done and most will get pregnant right. In those initial cycles. So if they're not getting pregnant or they need higher-tech, and I think once we're getting higher tech where we're talking use of daily gonadotropins, or we're talking, getting ready for IVF, then absolutely those need to see that REI.

I think another, good population can be egg freeze patients. And so, and this can be tricky. I think you're going to need more experienced APP to see those patients.  But in our practice, the APP see a lot of the new egg freezing patients for two reasons. One again, they're not infertile. Two, they need a lot of education and that's what APPs are great at providing education and really talking about what's their family building strategy. What's their goal? What do they want to do in the future? And we have that time to really dive in to those discussions. And then what we do in our practices, the APP does a bulk of that work.

Does all that management. And let's say if I see somebody and she has low diminished ovarian reserve, that was surprising or she's older. I'll do the bulk of the work, but then they get a free 30 minute follow-up with a physician, but then RE. So making sure they have those touch points. So that patient feels like they, again, they have this team working for them. And so I think that's another good population.

Griffin Jones: [00:31:15] Why do you say the APP should be a more experienced one if they're partly managing the fertility preservation program? 

Tamara Tobias: [00:31:24] I think an APP to be more experienced, to just to know outcomes and really understand outcomes from egg thaw, how many eggs, the age of the patient, things that could go wrong. And so I would have them more experience perhaps starting with egg donors.

Working with the egg donor population for maybe six months, eight months. So they really get a good feel of how a stimulation cycle goes, how the response goes, because you need to be able to answer questions. Why am I not responding the way, why did I have 11 follicles at my baseline? And now I only have four follicles and to really have that understanding of the IVF and the cycles and how that works, I think may mean more time and experience. 

Griffin Jones: [00:32:08] When did you see the role of the APP? Start to open up beyond just the third party coordinator role. When did you start to see REIs giving more of that work scope to the APP? Was it five years ago or longer? When did this really start to take off? 

Tamara Tobias: [00:32:28] I think you nailed it. I want to say five years ago.

Griffin Jones: [00:32:31] I think so, right. I know, I've only been here for seven years, so I can't really say, but it didn't seem like it was that way in the beginning. It seemed like there was a lot more people pooing it. And to me, it seems like even in the last, really like since this boom post COVID has taken it to another level, like maybe five years ago, this really started more people were doing, it started to be a little bit more accepted.

There were still some people that said now we're not going to do that. And then, this boom that has not gone away since last June. And it's forced people to revisit it. That's what it seems like to me. What do you see happening? 

Tamara Tobias: [00:33:08] I absolutely agree. I think the last five years, I think the volume has pushed it.

I think they're ,  busy and  they, their schedule is so full and they don't have time to do procedures. And then when they see that the APP  can do that, they're like, that's great. Or the problem visits or these new patient consults like donor sperm. They're like, yes. See them because I need to do my IVF patients.

Those take more time. Those are more problematic. Recurrent pregnancy loss. Those that are, really take longer, they're more, much more high, complex cycles where we can take, we can help and take some of those other cycle management off.  Another thing that happened because of COVID, I'll just comment on is we had that brief slowdown period. But when we did have that brief slowdown period,  in our practice in SRM, we developed a PCOS wellness program and you think a PCOS is huge and affects one out of 10 women. And it's huge. And our RE's do not have time in that consult that initial consult to talk about infertility.

And then. All the things that encompass PCOS is life has,  we could do a whole day talking about PCOS, right? And so this piece was program really now focuses on education diagnosis and managing symptoms and treatment of symptoms that the APP can do. So now here, our physicians were like, yes, have it go, go, because they don't have the time.

So we're doing those consults. We're seeing those patients and if they need to do IVF, then we're, co-managing again, we're there helping them manage lifestyle, obesity, insulin resistance.  We're helping that. And then the RE is doing the IVF portion of it. That's work. That's great. It's taken off. 

Griffin Jones: [00:34:55] It's taking off well with the example that you gave with your group, but it's also taking off that APPs are certainly expanding to their scope within the REI world in a way that we hadn't seen five years ago, I could see the pendulum swinging the other way and people saying, okay, we've got so many darn cases coming in and now new York's a mandated state.

And now progeny just landed 10 more companies. And so 800,000 more people in this state are insured. What have you? And I could see us or people just adding advanced providers and maybe not doing so in a way that's systematic. What problems could come from just doing this too quickly?

Tamara Tobias: [00:35:46] I think patient satisfaction, right?

If you throw somebody in there, there was one nurse practitioner on one of the comments that she made in our survey. And she said she went to the sink and swim university. And I think if you do that , you're setting yourself up for failure and that nurse practitioner is going to leave. You're going to invest time and money to train them.

And. And if they're not feeling satisfied or they're thrown in there, and they're not getting a nice balance of maybe doing procedures and new patient visits, but feeling comfortable and feel an educated and supported in that role, they're going to leave.  So yeah I think you could say your self up for failure.

If you don't invest in time to truly train and educate these APPs and then check in on them. How are they doing? Are you utilizing them to the skills that they're capable of? Do they want to do more? Or do they want to do less? Do they have a particular interest? So for example, we had an APP who really wanted to work with male infertility.

So we hooked her up with a urologist and it was a perfect fit. So could there be a role in your practice for that? And so. Yeah, I think you really, you have to invest and you have to do it right, but you can't go too fast. 

Griffin Jones: [00:37:01] When you check in on them. How are you evaluating your APPs? 

Tamara Tobias: [00:37:06] So for me, several ways. One is we have you can call at any time, right over if you have any question of the day. Then we have routine meetings. So routine meetings, quarterly, and those are like a two hour meeting where we could go through our topics. We have reviews twice a year where we sit down and have a formal review.

 We have peer to peer reviews. And so checking in seeing how they're doing on their patients. I check in with the physician. So all of my APPs have a physician mentor. I think that's really important as well. And cause that mentor is going to be my resource to check in, to see how that APP is doing.

Has there been any patient complaints? Has there been any grievances?  And that's important as well. And if there is, let's go back, like, was there a mistake on a procedure? Was there a hiccup or if there was let's readjust it, do we need to do more training? And really have a process for training. So it's not watch one, do one see.  What does it say? What does it say? See one, do one, teach  one, right? Yeah. No, you can't do that. You'd need to have a process. 

Griffin Jones: [00:38:14] Give us some tips for recruiting nurse practitioners, because  I could see this getting even more competitive than it is now. They're easier to recruit then REIs simply because there's only 40, 44 fellows a year.

They're just by numbers. There's more nurse practitioners, but it's not like they're so easy to get either. And so what's the best ways for recruiting and retaining them? 

Tamara Tobias: [00:38:41] That's a challenge. It can go both ways. So I'm gonna share my experience. I've had new grads and so you could go to schools and try to get a new grad.

The tricky part about that is if they have no women's health background or OBGYN experience in their background. You don't get reproductive medicine and your training, not so much. Right? So it's very focused unless you are a women's health nurse practitioner, you're going to be focused in on women's health.

But if you are a family, nurse practitioner, you're getting everything. And so is it diving down, and if you get a new grad, it may not be what they thought it was going to be. And so I would, then if it's a new grad, I would have them maybe do a, a day where they follow you just to watch. We'll see what's involved with that role before hiring them to see if this is really something that they're interested in .

Griffin Jones: [00:39:32] Not as a means of training them, but just as a means of them self screening, like who I want to get in to this, who do I want to run for the hills?

Tamara Tobias: [00:39:39] Yes exactly.

Yes. I had a nursing student come in to just to watch me for just a couple hours. And she passed out on the floor within the second patient. I was like, 

Well, do you really want to be a nurse?

Absolutely.  The other thing I would look is OBGYN practices. Now this can be tricky too, because you don't want to, but.  It's not so easy getting APPs it's I think it's a tight market everywhere, and we're struggling with medical assistance. We're struggling with nurses, we're struggling with ABP.

So  it's not that easy. you need to be competitive with your salary.  And it, and I think, like I said before, there might needs to be some in like observation first before you invest the time and money for training and hiring. 

Griffin Jones: [00:40:31] I suspect that matching of interest that you mentioned for the one example that you gave would be a recruiting advantage as well, because to a certain degree, depending on what market you're in, you may or may not be able to go to the top of the market for the salary that people are getting if there's a lot of demand and you're in LA, for example,  you might just not be able to do it if you're a smaller practice, but if you can say, okay, we have a few APPs and this individual wants to, I'm putting sub-specialized in air quotes, but  in male infertility, we should be able to give them that trajectory. I suspect that's one way when you can allow somebody to pursue the academic pursuit that they want, that gives you a little bit of an edge when you can't make up for it in material benefits. 

Tamara Tobias: [00:41:24] Yeah.  Another thing that we've done in our practice, we have a yearly conference this year was online, but  we do an outreach to the OBGYN community where we educate and train. And a lot of the program development of many of speakers are APPs. And so it's fun for a way to introduce what the role is and what is involved for people that have no idea. They may come out of school and they have no idea that this even exists as an opportunity.

Griffin Jones: [00:41:55] You talked a bit about what REI is, can understand better and more deeply about APPs. And now I want to flip it and giving you this seat to flip it, because I also want to make you blush a little bit, because I'm not gonna say who it was, but one person weren't said about you. They said that there's a handful of advanced providers in the field that the physicians look to as peers and Tamara is one of them.

And so I'm going to let you flip the script and say, what is it that APPs need to better understand about the REI and what they're going through?

Tamara Tobias: [00:42:33] I  think for me, for maybe for me, I just had such a passion. I've always had such a passion in the field and wanting to advance and grow and learn and just take it in another step further. And I think I've had RE's reach out to me actually and say, Tamara, I want to hire an NP. How do I do it?

How do I even start? And  I'm happy to share my orientation, checklists, my protocols. I have so many protocols and SOPs and what I feel is reasonable  for an APP, but understanding the boundaries too, because we're not an REI and I never, ever want even, I mean, that is such a specialty and I have  the utmost respect for all of our physicians. And I feel like I am there to help these patients and sometimes to help them and move them along that those, their journey, right. 

Griffin Jones: [00:43:29] You've given us so much to consider with how we bring APPs into the REI practice. How do you want to conclude for our audience Tamara?

Tamara Tobias: [00:43:38] Love the APPs, utilize us where we, I think there's practitioners, especially nurse practitioners who have our, we have nursing background for the foremost in that nursing. Component that, that teaching in us, the wellness, being a coach, being an advocate, just providing that empathy per patients, if they can see how we will work together with you. We are not out here to.  Take patients over anything like that? I would say I, especially in our practice, I see such a love for our APPs now and really looking at how we help grow the practice and we can help increase the revenue in the practice and we can free up time for REs who really need to be doing all those complex cases and that patient management. 

Griffin Jones: [00:44:28] And give people like me, marketers like me someplace to send all these patients. So God love you. Tamara Tobias, thank you so much for coming on Inside Reproductive Health. 

Tamara Tobias: [00:44:39] Thank you. It was my pleasure.