Dr. Eduardo Hariton 00:00
But not all practices are the same; other practices are going to be around in the way that they are in the future. So you have to really, and this is a hard thing to do evaluate whether you think your practice is going to do well in the market, right? Whether it's part of like a large multinational network, US based network, you know, geographic behemoth, as solo practitioner and academic center, like you're coming in to spend a lot of time and effort to come into a market and in a lot of markets, you're tied because you have a noncompete. Is your practice going to succeed in that market? Are they good points for long term success? And what does that mean that you join in the rocket ship at this point where they're already here? Those are hard questions to ask but important because you don't want to join a failing practice as their lifeboat. You do not want to be the lifeboat of the sinking Titanic, like you want to jump onto a rocket ship, or at least something that has a good trajectory.
Griffin Jones 01:03
How are young doctors getting screwed? Who cares how young doctors are getting screwed, practices are getting screwed, too. We don't talk too much about either party getting screwed. We do talk about pitfalls that employers face, practices face networks face, we talk about the pitfalls that younger Doc's face because Dr. Eduardo Hariton is the Forever Fellow. Hope he likes that nickname. Let's start it now. Everybody just call him that now. Because he went through this himself very recently. He's also written about it a lot and interviewed a number of experts himself. He and I have talked about it quite a bit. And there's a reason why he's been on the show three times. He gives a really good roadmap for younger Doc's. And I talked to him a bit in more detail than just the types of career paths that you could choose. We've talked about that a lot on the show, we talk more, we get more into the nitty gritty of the type of control that you're gonna need. If you're on the hook for certain KPIs. In order to be able to qualify for partnership, we talk about things that should be considered in contracts that both of us are loud about the disclaimer that we're not lawyers, you need to get proper legal counsel, we talk about what buying into a practice means or what partnership means, because that word is used to mean different things. We talked about different kinds of equity, like equity in the parent company versus equity in the local practice that while Class A shares, Class B shares, and the things that are important to you, that might not be in the KPIs, but that have to come out in the self discovery process as much as it has to come across in the discovery process with the people that you're interviewing. So I like to have both sides on the show. I like to have younger docs talking about what they're looking for. I like to have practices talk about what they need from docs. So if you have a different perspective, you're welcome on. Eduardo has been on the show three times. This is the sharpest conversation he has. He and I have had on this show. And my apologies to Matthew McConaughey. I didn't mean to say he was creepy. It was his character. I'm sorry, Matthew. Enjoy this episode with Dr. Eduardo Hariton. Dr. Hariton, my good friend Eduardo, Welcome back to Inside reproductive health for a welcome back for the second time, because this is your third time on the show. Welcome back.
Dr. Eduardo Hariton 03:41
Thank you. Thanks for having me. It's always a pleasure to be here and catch up and excited to chat more today.
Griffin Jones 03:47
You and I just talked about what we want to talk about, which is career trajectory for doctors in different phases, maybe mid level down to fellow and what they should look at. But we have something to solve first, Eduardo, which is the wager that you and I have, which we never actually specified a wager it was an I'm thinking it was more than a year it goes by a year and a half ago. Yeah. And we're talking about is fertility treatment going to be more or less expensive for the patient. In five years. I said more. You said less. I think that I'm we're a year and a half in three and a half years left. I think I'm right. What do you think?
Dr. Eduardo Hariton 04:27
Well, I think that you're a visionary. I knew that before. But I did not see the rate of inflation rising coming like you did. So well done there. I still got three years, we'll see what happens. And I think our wager was a donation to do believe your foundation. So
Griffin Jones 04:46
we never we never we never picked one for you. We also never pick this specific metric of the exact specific metric of what we're going to measure. So we hedged a little bit, but I'm I'm always happy to make a donation. But I do want to rub it in when I'm right. And I still think that I'm going to be right now maybe, maybe I lack imagination, as you did with the inflation, maybe I lack imagination of the economy takes a major dive. And that changes things. But I think that's what would be necessary. I don't I just don't see supply and demand consolidation. I don't see the prices coming down.
Dr. Eduardo Hariton 05:25
Well, yeah, I love to be right. But I acknowledge if I'm wrong, we'll see in three and a half years, don't don't take your victory lap too early.
Griffin Jones 05:32
Say, right. It is the first quarter. So let's talk about let's talk about something that you're far more right about, which is how doctors should be considering their careers. And let's maybe just give a little bit of a background for what you've done. I think it was summer of 2020. You that was one of the first things that you did where you did a digital event. For fellows. I was one of the speakers there. But tell us about fertility explained and then and then how that ends up being part of what you're doing for younger Doc's.
Dr. Eduardo Hariton 06:10
Yeah, absolutely. So we were stuck in COVID, take it back two years, we were at home, no one could go out on the weekends, everything was closed. And I had always had this idea that, you know, we're great at training, medical people who will train great training, and how do we physicians, we don't really share what else they need to know. So you get most of our area's go to private practice. And then they get this crash course and all these other things that they never learned about. So I wanted to use that opportunity where I had focused attention to teach the fellows about the business of fertility, you know, what is consolidation? What is a p&l? How do you market to physicians? How do they benefit manager industry works? And so I sent a bunch of emails expecting to get nothing back or maybe a few. And then everybody got back to me, you know, the CEO of the largest networks, you, David say, Well, David Adam, so like a bunch of people that really knew their industry, Natalie craft on social media, and I'm missing a ton. But they said, Yeah, I would love to teach the fellows. So we put together to four or five hour days, over two weeks of people coming and giving talks where they were open to questions. And it was an awesome event. People really liked that the feedback was solid. I found that it wasn't just fellows, I get emails from a bunch of people mid career and late career that said, this should be part of our education curriculum. It doesn't exist, because it's not our focus. But how do we keep this going? So over the last two years, I've kept that going, I haven't organized a conference. But I've done you know, usually monthly webinars with people that come and talk about how to get a job, how to, you know, get a job that you love, and it's people that been in the same job for a decade, I've had people who have switched jobs within two years, and they come and they say, this is what happened. This is how I got screwed. This is how they move my goalposts. I have people that talk about negotiation. I've had employment lawyers from my thermal come speak. And it's turned into this kind of more topical session where, you know, part of it is still teaching fellows about the business of fertility. We have one on the pharmaceutical industry, one on benefit managers, quite recently, we have one on high volume providers, and what do they do differently to be able to do 567 100 cycles coming up? But it's also turned into how do we help fellows equip themselves with the right information to get the job that they want? And that means understanding the right questions to ask understanding the timeline, understanding the process, and being empowered to say, you know, I have trained for 11 years medically, and probably a decade before that, I should be in a position to negotiate for the things that really mattered to me. And the reality is, we don't know what really matters to us as we're coming out of this process, because we haven't been prepared. But I hope to just give fellows a flavor of how to do that, and help them through that journey. And that's something that I went through two years ago, I interviewed at a bunch of places, and learned by doing with the support of some helpful mentors. But I hope to give the fellows those tools as well.
Griffin Jones 09:07
Let's talk about the job that they want. Because I suspect there's something operative about the front part of the phrase, the one that they want. I might regret saying this, it seems to me if you can't get a job. Right now, as a ra, you suck. That in fact, if I might even say if you can't get the one that you want, or at least go to the place that you want to go to that there's something that you're not doing right, given the demand. If you can't do it now, would love to see you tried doing it in the 90s when people like Dr. Serena Chen, Dr. Nedley told me that our eyes were delivering babies because there wasn't Rei jobs in in the 90s. And so let's talk about that. Do you think that I'm failing burning too much the demand side of the market right now. And if I'm not, then tell me more about what, how we define the job they want.
Dr. Eduardo Hariton 10:10
Right? So I'll say your second question first, I'd say yes, there is a huge supply side constraint, the very eyes, there are not enough of us being trained to meet the demand that exists, and certainly not that demand that is coming. So it's definitely the market that has shifted, as my partners like to remind me as well, 1015 years ago, how difficult it was to get a job. I would say, you know, if you can find any job, there might be something going on. Because I'd say the number of open positions and people looking far outstrips the number of people coming out of fellowship. But I would say if you can, even
Griffin Jones 10:46
ones that aren't open, Eduardo, people will say, yeah, we'd hire, we would hire somebody we might not like be actively recruiting right now. But almost everyone will say that they would hire someone, virtually all of
Dr. Eduardo Hariton 10:59
them. But I think the the other side of that is we are recruiting pretty early. And it's you could want a job. And if you decide that you want to start looking in your third year, that job for your year might be already filled. And some practices have an easier time than others recruiting. So some practices do feel some of those positions early. And there's only it's not that you don't have a need or that patients are incoming is that it takes a lot to open and find either the physical space or the support team. Because they're, you know, if you hire an REI, you don't just hire an REI, you need to hire two to three nurses, you need to hire case managers, you need to hire embryologist to support the volume that's going to come with them. So it's not just oh, I'll hire in Rei and everything else just happens on the line. It is a big process and clinics that do it, well do it really thoughtfully. So you could find yourself in a position where like, this is my dream job. But someone from that fellowship just took it. So I can either wait a year or go to their competitor. And that I think can happen if you don't time it correctly.
Griffin Jones 12:01
So let's talk a little bit about that. If there are universal must haves to for getting the job you want the audience might remember I had Dr. Dwayne o Welch on she's from outside of our field. She's a PhD psychologist and studies mating and dating behavior. I had her on the show, because I just wanted to show people part of the reason why their patients are delaying, why they're delaying family building. There's multiple reasons. But I think mate selection is a big one of them. So that's why I had Dr. Welch on. And it's my show. So I get to say, who comes on, she talks about having must haves for selecting a partner, and it's up to you, the whoever the selector is, to decide what their must have, I have to have someone who's politically liberal, I have to have someone who is religious, I have to have someone that loves the outdoors or loves animals, but she talks about there's two or three must haves that are absolutely universal kindness and respect. That they're not any of the three A's an alcoholic, an abuser or an adulterer, those those must haves are built in. So I suspect that many of the must haves will be people's preferences. And I want to talk about what they can be. What are the universal must haves, in your view, if there are some?
Dr. Eduardo Hariton 13:23
I mean, I would say, because the fellow that's coming out has usually trained for seven years in an academic center, that's usually all they know. So their view of what it is to be an area is very much clouded by the experiences that they've having training, which are for the most part academic, I think, if I think there is one must have, and this is not the most important, but you need to get paid, right? Most of us come out with that burden. In the six figures from training, most of us, by the mid 30s, are thinking about a family or already have one. And we have been pressed a paid what I think it's a suppressed salary for seven years of training based on the number of hours that we work and our expertise. So we're ready to make some money. Money is not the main driver. For most people. This is not the most you know, it's your it's a very lucrative career, you're going to do quite well. But there's a big opportunity costs, you're ready to make some money to pay some of your loan backs to buy the house that you've been waiting to buy. So money matters. It's not the main driver, but they need to pay you more than they paid you in residency and that's universally true. What else you care about. I do think it's very dependent. And we can talk about a path to partnership. We can talk about clinical autonomy, we can talk about protected time for whatever else you want to do, whether it is research, surgery, family, administrative, whatever it is, if it matters to you, that's something that that might be a deal breaker for you. And then there's all this other kind of you No smaller things that are more or less intangible. Can I teach residents? You know, who does my marketing? What does the IVF lab look like? Can I go into the IVF? Lab? You know, how am I paid? Is it what your kid model? I said a salaried model? Do I have an incentive to work? How much vacation do I have? How much leaves? Do I have? What complete looks like? Can I keep my own IP? Is it all owned by the company. So there's a million things that might matter a little, ultimately, for each person that's different. And what I hope to get Fellows is the ability to at least know the questions to ask so that they can form their idea. There's no perfect job for everyone, you just gotta find the perfect or the most close enough to perfect job for you as an individual. And I think the interview process is not something where I'm like, I know where I want to be. Let me just see who can get me there. It's a self discovery process in a way, because as you go, and you meet these practice owners and these physicians and see what their career like, you're like, Wow, I never imagined going to a place where you could have eight weeks of vacation that wasn't even in my idea. But now that I think about it, and how I grew up with my summers in my house with my grandparents, that might be nice. So your priorities might change as you explore the breadth of opportunities that exist outside of your traditional academic medicine path.
Griffin Jones 16:21
But I'm a millennial, Eduardo, I want all of it. I want all of these things. So I let's I do want to go down that potential different paths. Maybe we talk about how to rank order them. And maybe we talk about, well, maybe we talk about how much of them it is possible to have because this is not unique to our eyes is not unique to physicians happening everywhere in the marketplace where it used to be, well, maybe I'm willing to trade off some work life balance for a higher salary, maybe I'm willing to trade off some of each of those. If I work for something that's mission driven, I really identify with and a luxury, one sampled becomes a necessity. And that's what we're seeing when there is a undersupplied high demand dynamic in the market, which there is in the job market, which there is in the REI market. And people are like, Well, I just want I want I want the mission driven, I want the benefits, I want the salary I want the 40 hour, week or less I want the professional development. Everything that was once a trade off becomes table stakes is that not senior doctors very often feel this way about this is what's happening from younger ducks. Do you share that perspective?
Dr. Eduardo Hariton 17:51
I mean, I think yes, and no, I'd say you can't get everything you want. That you know that if and if you find that job, then good for you. Like that's great. Like, if someone's willing to give you everything you want in the location that you want for the salary that you want, then you did really well it means that you have come into a market that is favorable to you. This is a capitalist economy, someone thought that you were worth all of the things that you wanted. You know, my advice for Fellows is like, Yes, this is a fellow's market, but you gotta come in humble, like you can come into these conversations being like, you know, I work on gold, because I just did training for seven years, and everybody's looking for fellows and coming cocky, because it's not that they can give it to you or that you're not worth it is that they're not gonna want to work with you, right? Like, you're recruiting the person that's going to take care of your patients. And at the end of the day, we're all here to take care of patients. So if you don't like the interactions that you have with someone during the interview process from the practice owner side, it's not that they're not the right person for the job clinically, or they don't have the right expertise is a you don't want that partner, you don't want that person taking care of your patients. So it's really important to Yes, advocate for what you want, but come humbled to the conversation. We don't learn everything we need to learn. I mean, I've been at my job for a month and a half. And I'm learning a ton every day from my partners, and I went to a great fellowship program where I had great faculty. So this career is a lifelong process. We need to continue to learn throughout. So come to that conversation humble as to like whether you can get everything to one. The answer's no. Like there's an idea that the practice will have of what they want to offer to you. And you come with an idea of what you want. You know, ideally, you're coming from a place where you're close together, because this is the right job for you. But you might say no, it's really important for me that I'm able to take six weeks off a year, even though your standards for because my family is abroad in Asia in India and I want to take some time to go see them. And the practice has to decide, is that something that we can do in our model, can we make this work for this person we'd really like them otherwise So I'd say, some practices, you're so far apart that, you know, even though they want you and you want them, you just can make that work, someone has to compromise. When you're close together, it's a matter of saying what really matters to me, you're not gonna get everything you want, that is very rare. But you got to figure out what's really important to you and ask for a couple of things. And I think that that can be done in a tasteful matter where you come from a place of compromise and trying to make this work. Or it can be done in a place where you feel like you're negotiating with someone that you don't ever have to see again, and that's the opposite, you're gonna see them every day. So you have to be really thoughtful about how you approach those conversations,
Griffin Jones 20:42
I want to jump back to that process of prioritization, I want to stay for a second on the employer side with a notion that you mentioned of the interview is essentially a sample of the working relationship. If you're not getting along and the interview process, if you can't see eye to eye, then that's going to be indicative of how it would be like to work for work with each other. That is fairly conventional wisdom across hiring. And many of us. Probably the vast majority of us at one point or another in the last two years or so have ignored that conventional wisdom have ignored that. Gut feeling intuition, because of the necessity if you have embryologists that are about to all quit, because the because they're so slammed, and there's one or two in there that that's not a good cultural fit. I don't like having them in the office, it's really hard to fire that person or part ways with them, because it will hurt the others, and it will be really hard to replace them. So many have ignored that wisdom. And and so what is your view on that? To the extent you can speak to it?
Dr. Eduardo Hariton 22:11
In terms of like, what happens when you have a bad apple in? Yeah, yeah. So
Griffin Jones 22:16
you said, Okay, you'd said to the employers, like, if it's not a good fit, just, you know, it's not a good fit. But if almost all of the cohort is coming in, and they're all wanting things that aren't a good fit, and the leverage is so tilted in their favor, and you've got a 10 week waitlist, and or you've got five years to sell your practice or three last, let's say you have two or three years to sell your practice. And you know, you're not going to get that much for it unless you have somebody underneath you or somebody else working alongside you. What about that concept when it's tilted so far against your favor, that it's hard to do the right thing?
Dr. Eduardo Hariton 23:01
Well, I mean, I'd say that's a complex question. You know, if you have someone in your group, that is a bad apple, but you need them for a certain expertise in a market that's really tight. That is a very tough situation. And you have to weigh, you know, is this person bringing down my employee morale, that my overall productivity of the company is suffering, and we that we would be slammed, but I'd rather take his salary and give it to other people and pay overtime. And that's going to make people happier, because they're getting more take home pay, even though they're working lower hours, maybe, maybe it's worth having this bad apple because the system breaks without them. I can't get rid of them, I'll do my best to replace them. So that's a very complex decision. I don't envy the lab directors that are trying to hire embryologist. They are in a similar bind, that sometimes the practice owners are in recruiting areas, because we are growing too fast. And you've had a lot of smart people thinking through solutions on how do we address that gap? How do we increase access? Not our topic today, but I'm sure you and I will talk about it at ASRM over lunch. That being said, on the hiring side, it is challenging to hire someone and you have these things were like yeah, they're not the right fit. But it's the only person that wants to come to my small market in the last two years. And I'm looking at an exit. So from on one hand, yes, that, you know, practice director might say I don't care about the working relationship, or their personality quirks. I need a person and I need them now. But when you think about it from the shallow side and your like, this person really needs you. They don't want to hire you but they will for their own interests. You think our from the fellow side that's not fair to the fellow either, right? You're going to a market so that someone can sell their practice. I bet you they didn't hire you and tell you how I'm gonna exit in two years. You're gonna be you know, your job is gonna completely change. I bet you they said, Hey, this is a partnership track and we are going to give you a great salary and support you and I'll mentor you and you know, I'm there He's still here for like 510 years, which is probably true, at least for five. So, you know, that dynamic plays both ways. And and I think that, yes, the standards might be lower for some people, because they don't have a lot of options. At the same time. You know, it is important for all of those to come to the table and be forthcoming. And, you know, you might not walk away from the person like you did before as a practice owner, but you should really think about and if you need them, you need them. I don't think we're going to solve that one today.
Griffin Jones 25:34
Well, let's talk about some more of that when we talk about how young dogs can get screwed. But let's revisit the prioritization self discovery process, you mentioned that the interview process is a self discovery process, that very often you're finding out what's most important to you by being exposed to others that know how much self discovery should be done early on, I believe that's just, that's inherently true as sales process I learn more every time I have a sales conversation, I learn more every time I interview or hire someone, the more that I have up front, the more sophisticated I can be with that discovery process, the more and the better experience it is for the other person to because it's a better way of assessing fit. And you yourself, when we were friends, when you were going through all this stuff, and you knew what was important to you at a general level. Like I think you learn more along the way of what was possible. But you thought about what you wanted. And then it became more refined as you went through the process. So what what should it be to start with? Is it as simple as writing down the must haves and putting one at the top and trying to clarify them as much as possible?
Dr. Eduardo Hariton 26:57
Yeah, I mean, I think I would say I kind of knew what I want. And I still discovered a lot, but I had a sense of things that mattered to me. And I think that that's important. You know, when I think about them, like you kind of know if you have a location preference or not. And that may make your sense search really broad and not separated at all, you kind of understand the the practice type you want to be and the usual split is academic versus not, although now we have a lot of private EMIC practices, which have academic affiliations, but are still working in the traditional private practice model? And then from there, the list goes on, do you want to be fully clinical? Do you not want to be fully clinical? And you make this list of things? So I kind of wrote those out. And they said, You know, I want how do I want to spend my time? How do I? How do they want my week to go? And, and you craft that vision? And then you look at the options. Like let's say you were someone like me who wanted to be in the San Francisco Bay area, I sketched out all the practices that were out there. I talked to mentors who knew them to get a sense. And then I talked to the people at the practices and said, What's your day? Like, you know, how, you know, how many patients do you see how does it work, etc. And you can go down the line. So yes, you have to have a sense of what you want, because that's going to help guide your conversations. And that might save you some time. Like this is a hard, long process, you get to meet people who are also busy, you take time out of your day. So if there's 10 practices in your market, you automatically can probably discard half of them by just knowing that the model might not be somewhere where you want to work. And they can tell you, you know, intangibly like there are practices that are very set in their ways, because they're part of large systems. You know, someone like me, I like to go and I'd like to see a problem and try to fix it and like talk to my nurse and talk to my practice manager and be like, how about we try this? I think this might be better. How do we flip these things around? I knew that at some of those places, there is no way that that could happen. That's a great, we put it on the agenda for q2 2023. And we'll talk about it then. And that would slowly kill me inside. So I knew that yes, that play, plays well, and does good IVF and has great colleagues. But that was not a right fit for me, in terms of the place that I needed to work. So you, you figure out these things as you go. There's all of the things that through the process of talking to people, I was like, wow, this is really valuable. I didn't even think of that didn't even make my list. But let me go back and ask these other four practices, how they do this thing? Because that's something that's informative, and that's part of the self discovery process. Should you know what you want? Yes, absolutely. So that you know what questions to ask. But I guarantee you that even if you're the most prepared person, you will figure out a couple other things that you care about through the through the process.
Griffin Jones 29:58
That's absolutely right. And especially Sometimes you see the limit to your own imagination. Once you see something else that's possible, we could exactly further develop that thread and talk about potential career paths. I do want to touch on it, but I kinda want to bring them in tangentially, because we have talked them about them in the show, I want to talk, I want to introduce them as they become relevant in the conversation, I want to tilt a little bit more to the direction we touched on 10 minutes ago of how young doctors can sometimes get screwed, because that's what that's what a lot of people are tuning in for. And we talked a little bit about how employers can get screwed. And I do want to talk about that too. But what are the pitfalls that you're seeing that are common when when fellow fellows or other associate Doc's, or even folks in their halfway through their career are running into when they're signing with groups?
Dr. Eduardo Hariton 30:53
Well, I'm no longer a fellow fellow, and Associates now. But I do feel like I'm still in practice, because I spend a ton of time talking to fellows going through this process. And it's one of the parts Yeah,
Griffin Jones 31:04
you're not always fellow you're, yeah, you're the the non creepy Matthew makhana, hey, Rei fellowship, you're always going to be around the high school in a good way.
Dr. Eduardo Hariton 31:17
That's why shave everyday still look young and not out of place. But that's an important question. And I spend a lot of time talking to fellows for that exact reason, because I hate seeing the other side, when they're like, Man, I got to this place. And like, that is not what I felt my contract said, and I didn't realize I was going to be in a satellite in like, you know, the third ring of this major city. So it is really important to do a couple of things. And this is not an exhaustive list. But I think you really need to get to know everybody in your practice. So I joined that seven physician practice. And I am incredibly lucky, because it's exactly what I expected coming in, but I spoke for at least an hour to every single person there. I wanted to know where they're from, how they came, how they were treated throughout a, you know, I spoke to a person who left the practice to understand why did they left? How was that relationship? You know, was there a sour taste, I wanted to know what happened. And you know, it was a positive experience, which made me really reassured, but you want to really spend the time getting to know the people that you work with. And listen, you know, some practices are so large in a given market, that you might not get to talk to everybody, they might not want to talk to you. But if you can only talk to one or two people, and they really keep the other ones at arm's length, that's probably not a good thing. So spend the time especially as you narrow down into your top choice top couple, spend the time getting to know those people, I talked to the nurses because I wanted to see how they felt. I talked to the lab director because I wanted to see what the lab culture was like, You know what that, you know, what's the lab hiring practices going to change my decision? No, but this is someone that's gonna be your go to person to call. So you kind of want to know what that buyer is, like, I like think that that's important. There's this
Griffin Jones 33:08
piece of advice to get to know everyone in the practice come from people running into Well, I I love Dr. Hariton. When and I really got to know Dr. Erickson, but then I found out Dr. Jones is total aihole. Or that the nursing manager has Dr. Hair done in a vise and, and nothing gets done? Because she's the bottom eight are you hearing about these things happen, and that's part of the dissatisfaction?
Dr. Eduardo Hariton 33:39
Well, it's more of like, hey, like the person that they put in front of you, it's either happy or really incentivized to, or you, but you have might have a group of people that's not happy, that feels like their contract, and, you know, they're not gonna come out and like, you know, spill their beans to you. But you can get a sense from a conversation, is this person super satisfied? Are they you know,
Griffin Jones 34:00
exciting times, they will. Sometimes they will sometimes saying like,
Dr. Eduardo Hariton 34:05
but that's what you want. That's exactly what you want. You want the canary to sing before you get into the coal mine. Like, you really want to know what's happening. And then there's imbalance, there's like, everybody's so good. We love working with our doctors, like, you know, they really take the time to teach us they give us independence, or like, yeah, you know, you know, the doctors are nice, we have a couple of things to fix. We're always working on it, you know, we're excited to have some fresh blood, like, you know, it's a different conversation. It doesn't mean you can't go there, but go there with your eyes open. So that's one thing. I think the other thing is compensation, right? We all want to be paid fairly. And it's not all about the money, but that money, the money is a reflection of what you're worth to them and the value that you're bringing to the table. And let's be real, like this market is growing and we need more physicians. So you are very valuable. You might lose money for the practice as first as you ramp up, but over the you know, Multi decade career, you're going to bring a lot of value to this practice. So you need to be paid fairly. And there's multiple compensation models, when there is salary, salary plus bonus, eat what you kill. And more importantly, that changes over time and usually changes to become a partner. I think a big pitfall I see is people going from a high upfront salary, without realizing there's a reason why they're paying you so much. It doesn't mean that, you know, a high salary is a bad thing. But if someone's offering you something that's like 50, or 100%, higher than everybody else you've talked to, there's probably a catch, right people and don't just dole out money for no reason. So understand how you're being paid, understand what your metrics are, understand what you control on your metrics, right? Because if they say, this is what you have to do to get your bonus, but you have no control over that, then you don't control your ability to get your bonus. And that is challenging, and a bad incentive design. And I think more importantly, understand what your career trajectory at that practice looks like, you know, everybody says, you have a partnership track, you know, except if you're in academia, for the most part, most people say, you know, after X time your partner, well, what does it take to get there? Like, I like, I asked practices, like, you know, what are the metrics, and some of them put in in contracts and say, once you hit this revenue, by this time, you know, that you're considered a third partner, so you know, what your goal posts are. And some say, once you get to three years, we consider you for partner, but you don't know what you're shooting for. You don't know if you're doing well. So I think really defining that is important. And even more important that that is, what does being a partner mean, you know, everybody calls it partnership, but are you actually buying into the medical practice? Are you putting money down? You know, are they lending you the money? Are you taking a bank loan or taking it out. But also, some people call it profit sharing a partnership, there is no equity exchange, there's a profit pool that you get to participate in, that is not a partnership, that is profit sharing. And you know, sometimes there's now a lot of like the back companies, a lot of which you've talked to, that have equity in the MSO, or the top organization? How are those shares are located? Are they class A? Are they Class B? What does that mean? Are you actually gonna get it? Are there options that are worth nothing unless a company doubles, or triples in value, and they go in the money? All of these things? You know, I don't feel like even after doing this for years, and trying to understand that I have every little part figured out. And they spend a lot of time on this. So how can you expect someone who has been in a traditional academic career for seven years to get handed a multi page contract and understand that you can't, but as a fellow, you have to spend the time and you have to spend the money understanding with a lawyer what these contracts mean, and you might have nothing to do to change it. And it might be a great structure. I'm not saying one way is better than the other, although I did vote with my feet. But I think it's if you don't understand what you're signing, then that's a real setup to being screwed. And then the last thing is, understand your clinical practice, understand? Are you going to work in the satellite? Or are you going to work with people in the main campus? What does your schedule look like? Do you have control? If your kid needs to be picked up for school at 3pm? On Wednesdays, can you actually make that decision to make that, because you don't want to figure out what the bounds of your schedule are? When you show up the first day, that's a setup for failure, you want to ask and say, Listen, I don't need this every day. None of these things are non negotiable for me. But I want to understand, can I start at seven, so I can be done at three, or mindset for a number of hours like getting you actually Lilly put me in a satellite that wasn't even built when I started two years ago, because you might not want to drive an hour here, there. We put that in writing. So if you don't want to drive an hour, just say I want to be working at the main campus. And you know, there could be a ton more. That's why I spend time talking to fellows. But there are a lot of ways and the best thing you can do is equip yourself with the right questions. So as I have a list that I circulated that I made for myself, and then I send it out to the fellow so happy to share it around. I'm sure it's floating somewhere. But you really got to ask the questions and spend the time.
Griffin Jones 39:30
One thing that you can think about when you're looking at which practice to go to to judge how forward thinking they are, how state of the art they are, how embracing they are of the new technology to improve patient relations to improve workflow for staff is are they using engaged me I wish I could remember who first said that to me was the younger doc when they were talking about what type of practice they were looking for and what other people should look for. Everybody can say that They're forward thinking. But what's the evidence and one great piece of evidence is using engaged MB when half the practices in the United States and Canada are using engaged MD. It's something that dramatically improves workflow for staff, especially nurses, but also providers and other staff, it helps improve the quality of informed consent, it improves patient relations, because it puts the experience on their time in a cadence that allows them to be informed and then use their time with providers and staff and nurses to be personalized, personalized, individualized care for them engaged md.com/griffin We'll get you a free workflow assessment. Should you be using engaged MD as a means of flexing to attract Doc's it'll help, but it's really going to help your patients and your staff go to engage them d.com/griffin. Now back to enjoying this episode with Dr. Eduardo Hariton, we've got a ton of meat here. So I want to go through it surgically. And I want to start with something that you said about salary, how often people get big eyes when they see a salary number, and maybe they're leaving something on the table of for equity, for example. I want to talk about what the things that you think that they're leaving on the table for salary? Is it just equity that they're leaving on the table? When they when they see big salary numbers? What else do you think they're overlooking,
Dr. Eduardo Hariton 41:40
they're probably overlooking controls. Because like with equity comes saying the decision making and some degree of control. So it doesn't mean that you can be a practice, like, if you're in a market that is hard to recruit, you might need to put out a pretty big salary. And you might still have a true partnership track. So I'm not saying that if you have a high number, the rest of the salary, the rest of the experience, or the practice is gonna be negative. Sometimes it's not. But you gotta really, you know, open that second eye and really look deep. And understand if that's the case, you could if you have a high salary, what does that mean? Do you mean, you have a high base and not a ton of productivity incentives? Is that a long term sustainable model for the practice? are, you know, are your partners working really hard anyways? And are they paid in the same way? Or do you have a high salary, but it's, you know, a very low base, and the rest is incentives, right. So if it's production incentives, you're getting paid up to this high salary based on the number of retrievals, you do. And then you look at your contract, and you look at the volume that they're doing. And you say, Wait, in order to get to the highest salary, I have to do the same number of retrievals, as the top producing doctor in this practice, who has been here for 17 years, that's gonna be hard to do in your first couple years, right? So don't you know, the numbers are six figures and look impressive, when you've been making, you know, a fifth of that, but you really got to understand like, how is that money going to flow through you? And do you really have the ability to get there? And I will tell you sometimes, yes. And a lot of times no, like, these contracts are written in a way that they look exciting. But when, when push comes to shove, you know, you can, you know, their most productive fellow out of practice will never meet the numbers that they need to get to there. So it's important to understand that, well,
Griffin Jones 43:33
let's talk about equity and control, starting with equity and understanding a little bit of different kinds of equity. So you have a lot of people reaching out to you. So President, I have a lot of young doctors, bye, bye. Eight or 12 times a year, I have young doctors reaching out asking me about what they should do. And I do the advisory for free, because unless they're unless they're thinking of starting a practice and like they have plans to start a practice, I'll charge them a little bit for a consulting engagement. But the reason why I do it for free is because they have just enough knowledge for it to be valuable for both of us to have the conversation, but not enough to be able to tell them what to do they, they like me because I get to talk to so many people and I don't have a dog and fight. I don't work for practice or anything. But there's still a lot that I don't know. So in many cases, I can just tell them, what I see. And something that I'm seeing recently that I don't know how to say I can't categorically say which is better. Maybe one isn't universally better than the other but there's parent there's equity in the practice itself, the established business in most cases, or there's equity in the parent company. Sometimes there's both I can see pros and cons to each of those. The the if it's equity in the locally owned practice, then there's that's the established business. That's the one that's already made money that's probably going to continue to be there. Whether they're under different ownership in the future or not, I can see pros to the parent company and that they're growing. That's the one that the PE firm hopes to flip for a lot more. And you can increase that multiple by acquiring more practices and making the network bigger. But you could also go bottom up like Integra med. And so what do you see as the pros? And is do you think one is generally better? Or worse for equity in practice versus equity and parent company?
Dr. Eduardo Hariton 45:34
I would say that, you know, after spending some time they said, say, you can't answer that question with looking at the specific company. Because the way that the structures work has gotten incredibly complex in terms of how they're issued, how the transaction happens. So saying, broadly, you can say yes, you are incentivized with the investor. In the same way, if you have equity at the parent company, and you can say, you have a little bit more control over how much your individual practice produces, because you're working there. But you might not benefit of what the other markets are doing, if they're doing really well. One might be more risky, one might be less. But the reality is, you can answer that question unless you're comparing, like one deal at one structure at one company versus the other. Because the way that they're issued to you whether you have to buy them, whether they're options, whether they have, you know, some sort of strike price, the tax implications, sometimes you get granted equity, and you have to pay the tax bill when you're granted the equity, but you have no cash to pay the tax bill with. So all of these things are difficult to you know, talk about in you know, kind of broad terms, because they are so different. And you have to really understand the the nitpicky parts of each, I would say, I find, at least for me, it was important to be able to share in the value of what I helped build. And I work very hard. And I love what I do every day, I love what I do. So I want to make sure that I say work hard and keep growing and hopefully add value clinically to my practice and add value to my network in terms of my other roles, I am able to share in in that and that profit. So you you I don't want to give advice of what model is better, because it truly depends on the individual situation with the employer that you're looking at. But I do think it's important for you to understand how and when that value might come. And also know what kind of incentives does the value that you're getting, provide not only for you as an individual, but for everybody else around you. Because if you are incentivized only for an Exit Multiple, that's going to drive a much different behavior in your partners and the people around you than if you're incentivized on a clinical production site or whatever else it might be. And, and you have to be really thoughtful about what what culture that builds.
Griffin Jones 48:17
So did you focus more on the parent company or the practice as you are having the attitude of I want to be I want to have a piece of what I'm helping to build,
Dr. Eduardo Hariton 48:27
I wanted to focus on a model that would allow me to have a partnership that over time became equal to the people I worked with. And I didn't really care if it was one or the other. Ideally, it's both right. So you have partnership in your local level, and then you have partnership in the parent company. Because it's truly well aligned. I think the other part that was important to me was that he was completely transparent. What that was like that it was, you know, I know exactly where I need to be in three years, how much I need to produce, I know. And I know what that means for me. So over time, every three months, I plan to truly track Am I on track to get there? You know, what am I doing better? Let me sit in the console with a cup of my amazing partners and see, what is it that they do differently than me because they're converting better, or they're patients like, stick with them. And I think that's the whole culture of learning. That's also why I joined a network because I also don't think my practice I love it. We are not the best at everything. But someone down the street on the other side, like we are part of us fertility, someone on the other side of the country might be doing something better than us. Let's fly there. Let's check out that lab. Let's check out that marketing department. Let's share best practices. And I think that that was part of the value of of having a bit network is that we can learn from each other. I think another thing that I didn't mention that I find important is not all practices are the same and not all practices are going to be our around in the way that they are in the future. So you have to really, and this is a hard thing to do evaluate whether you think your practice is going to do well in the market, right? Whether it's part of like a large multinational network, US based network, you know, geographic behemoth, as solo practitioner and academic center, like you are coming in to spend a lot of time and effort to come into a market and in a lot of markets, you're tight because you have a noncompete. Is your practice gonna succeed in that market? Are they well points for long term success? And what does that mean that from you join in the rocket ship at this point where they're already here? Those are hard questions to ask. But important because you don't want to join a failing practice as their lifeboat, you do not want to be the lifeboat of the sinking Titanic, like you want to jump on to a rocket ship, or at least something that has a good trajectory. And you have to figure out what that is.
Griffin Jones 50:57
There were a lot of people on lifeboats in the Integra med situation that they wish that there were a lot of people that went other places after that, that happened. Not at every practice, of course, it's different, but that the lifeboats happened a lot. And I do want to talk about the type of control that's necessary to achieve the outcomes that are specified should be specified for sponsorship, I want to say a, for a second on the equity of, of parent companies and versus salary versus practice, because I looked at an agreement recently, that the salary was high man, and the and the the signing bonus was high and it could have been taken in could have been taken as equity could have been taken as, as cash, it was gonna be more if it was equity, and less if it was cash. And so that was a that was a scenario of both both like the the equity signing was high and the salary was high. It's, I've found that the networks that are overpaying the most both for practices in terms of multiple, and for Docs, are the new ones on the block, that they just got that, that huge money from the PE firm, they just found a practice to buy, and they're putting the networks together. And of course, there's been several of those in the last year and a half. So when I'm looking at this agreement, and I'm trying to advise these, I can only tell I can't tell them what to do, I can only tell them, what I'm seeing is that, yes, it would ultimately be more valuable to take the equity. But what do we know about these guys? Like they just came in from Wall Street got a couple docs together? And, you know, it's like to even know the chief medical officer is yeah, do they even have their flagship center purchased yet? And they're like everybody else are gonna be putting all of this stuff together as they're flying the airplane. And so it was hard for me to say what was more valuable, the cash or the equity? Because what if there is a 40% drop in the market? What if the Fed does have to raise interest rates to 10%? There's no more free money. And some of these people have to cash out for their limited partners, and it just goes belly up, like, what do you see?
Dr. Eduardo Hariton 53:38
I think it depends on the network. Right? It's a hard question. I don't know. I'm talking about one of
Griffin Jones 53:42
them. Like, it's not a specific one. But it's a but it's somebody that's come around in the last year and a half, let's say, and we're not singling anybody out. Because there's multiple yeah, there's enough. Yeah. And there's gonna be yeah, by the end of this episode, there's gonna be five more so. So like, it's one of the new ones. They're just get people to gather, whether they've come out in the last two years, or in the coming two years. So it doesn't even have to be somebody now, but they they're clearly building the airplane as they're flying it is, is is the equity still worth more than the cash with all those unknowns?
Dr. Eduardo Hariton 54:22
You will know the equity is gonna be discounted discussion, head is always king. But if you want some upside and meaningful upside into the future, you should take that equity. So this is how I don't know the answer to that. But this is how I would evaluate a decision. I went to lunch for two and a half hours with the managing director of the PE firm before I joined because I wanted to understand their goals. I want to understand who they were, where they were coming from, what was their vision, how do they see physician autonomy? Like how how do they partner like people, you know, just
Griffin Jones 54:50
want to be clear for the listening audience. While you're not talking about Mark Segal, the CEO of us fertility just stepped down. You're talking about the managing director of have you on Capitol?
Dr. Eduardo Hariton 55:01
Yes, J rose went to LA. I mean, I was lucky, we live in the Bay Area 30 miles from each other. It was important for me. And I'm not saying everybody has to do this. But this is a way to approach it. We went to lunch. And he asked me questions about myself and my vision about the future. And it seemed questions about himself and his vision about the future. And you want to make sure that you're joining a network that sees the future fertility in the way that you do. And the network that where they are willing to make investments behind things that might pay off during their holding period. And some that might not, but are important to the success of the business or at least are important to you. You want to understand how they see physician autonomy, what are the things that they think we should centralize? What are the things that should say at the practice level? It's kind of the US, you know, there's states and there's the federal government, and there's decision making that needs to be outlined. And you know, in our network, physicians have a lot of autonomy, because they are still owners, and they are still on the board. So these are the kinds of things that you can do. I think the other way to do it is that that private equity networks, those networks that are growing fresh with cash just off the boat, they have managed to convince physicians that they have the right vision. So you're joining a medical group of ARIA eyes that was already convinced for the vision. So you can ask your partners and say, What was it about private equity X or Y or Z? I mean, I'm sure you had five offers, why did you pick this one? What is their vision? What do you hope will change over the next five years, private equity gets a bad rap, some of it deserves some of it not. But all not not all of them are alike. And they're actually very different in their strategy and approach to entering our field. Some of it is a traditional rollout calling cards growing, you know, margins, EBITDA, and selling, some of them are thinking of doing different things. And the value that they hope to bring to the table is different. And I tell this to fellows, and it's something that I think about myself, the lifespan of investment for these companies is three to seven years plus minus a few, right? So we recruit two years ahead of time, sometimes longer, there is a good chance that the person who is partnering with your network, by the time that you're illegible for partnership will be different, there's nothing we can do about that there's no fellow that can negotiate that, oh, I want to say in this exit, that just doesn't exist, right? It's an investment, it might happen. So you really gotta trust the vision of the network. And you have to trust the vision of your partners, because they make that bed with a lot more at stake than we do when you're joining a job. You know, this is their baby, their practice. And they chose to partner with this group. And they bought into the vision knowing that that vision is going to change, you can choose your second wife before you choose your first one. But you really got to be comfortable with the attributes that you care about. Hopefully, you'll make the decision. And you're going to have less control about the second one that the first, but you really gotta believe that both the private equity company and the network of physicians are aligned in what that looks like. And unfortunately, in some cases, they need Him because that's the way it works. And in some cases, they don't need to be aligned at all. So it's a leap of faith. And that's why I think it's the most important thing to me, is, am I working with partners that I trust and respect because at the end of the day, 90 plus percent of your interaction will be with the people around you at your clinic, not with everything else, and you just need to be comfortable with that.
Griffin Jones 58:42
Fair enough that they won't have a say in the exit. But should younger Doc's be looking to have a no assignment clause in their contracts. And if they do go for that, is that something that the that the other party, the network, or the practice would, would would stomach in a negotiation? So a lot of people don't even know what an assignment clause is, meaning if there's no assignment, if I can't sell the contract, or the contract doesn't transfer if I sell the business, but in an assignment clause, one party can have assignment and the other cannot, they can both have assignment. You wouldn't really be able to sign your contracts some other doctor because that wouldn't work with it. But can you ever notice Yeah, no, I work as a doc that says if you sell my contract does not go to the I don't know if that's something that I
Dr. Eduardo Hariton 59:39
think that's really challenging though, because, you know, you have to understand like yes, you have leverage and you're coming out and you're in demand, but the practice invest a lot in getting you to play right, right. They they build a team for you. They lose money for on you for about a year it takes a while to get ramped up, your new patient visits will trickle through. They get to me so it's up They get investment for the practice. And so I don't think it's fair to say to a practice, like, yes, our investor change, you know, all of our partners are still here, everything is still the same. We haven't changed anything of the goalposts that we gave you. But now you can walk away with, you know, and void your noncompete and go to our competitor, when we build you up for two years, because they now have a ton of cash and when, you know, incentivize you, I think that's unfair to the practices in some regard. So if you can negotiate it more power to you, but I think realistically, you know, no, that diminishes the value of the whole network. Because if you have, you know, 20% of your physicians or 30% of our associates, and the moment you sell all 30%, can walk out the door with no ramifications, the person buying is not going to want to pay for that. And that's going to take a hit. So, you know, I don't see that as a super viable model long term. But at an individual level, if you're a felon, you can negotiate that. And that's how you feel protected that your family's in Houston, you're wondering, you're stoned, no matter what you want to stay. So you need that safety. Maybe, maybe that's something you can do. That's why every contract is different. And you need an attorney to walk you through what those means. But I think at a broad level, that's probably not something that's going to work for most.
Griffin Jones 1:01:19
It's also different from a non compete. So okay, so that's generally probably not in the interest of the employer. That's how the employer could get screwed. Let's talk a bit more about the type of control that you need for Revit. Well, actually, let's first specify the market. So you said, you know exactly what you need to do to hit partnership. And this is what over two years or three years? Three years? And you're reviewing it quarterly? What are you reviewing quarterly? Is it IVF? cycles? Is it billing in dollars? Is it number of patients,
Dr. Eduardo Hariton 1:01:55
everything like I you want to practice subtracts those, all of those things, because those are all important. I want to know how many new patients I So how many of them converted? What dollar amount, those lead to how many cycles I'm doing, and knowing that this is where I need to be, like, Am I on track? Like, you know, if I keep going at the same trajectory? Am I gonna hit that? What do I need to do? You know, if my conversion rate is not what I would like it to be, I can work on my conversion rate, or I can add more new patients. So maybe I just need to work a little harder there. There's no right answer there. But you need to know what you need to hit to make it to where you want to be. And, you know, this is a separate question. But I talked to a lot of practices that don't track anything, they don't track productivity, they don't have a dashboard to see what people are doing. Some people don't even track the lab on a weekly basis, they track the lab on a monthly or quarterly basis. That to me seems
Griffin Jones 1:02:51
the bridge makes them. Yeah, there's a lot of people that don't
Dr. Eduardo Hariton 1:02:54
listen, you cannot improve what you don't measure, I'm gonna save it again. Because it's really important, you cannot improve what you don't measure. So it's really important to go to a place that knows how to measure, you will not know if if things go south, and you can pinpoint the problem, because you did not establish the systems that you needed to understand what has changed, it's going to be a fire, like you're really need to measure. And it doesn't mean you know, people are moving that direction. This is all like CEOs breathe. And I think that's part of the value of these networks. professional management does this across healthcare, and they're bringing it to fertility to some degree. Sometimes it doesn't feel good because you you're not doing so well. It's uncomfortable to be measured. And it's especially uncomfortable to sometimes measure against other people, we are uncomfortable with that. But that is the only way we're going to improve. So me as an individual, I want to be measured, I want to know what I'm good at. I want to know what I'm bad at. I want to know who's good at what I'm bad at. And I want to go spend time with that person to get better. And when you leave that ego at the door and say these metrics are not meant to put you down or single you out. They're meant to bring you up to standard and make you better. And by that, you know, racing tides. What's the saying like racing tides, you know, make all boats go out for boats are lifted in a rising tide? Yeah, this is the lighting way of the thing that code, everybody will go out before measuring. So I found that that was another thing I didn't really think about when I was going through but as I saw, I thought everybody measured because where I trained, we had a methodical lead director that was good at measuring. So, you know, is it important? I didn't think so. But now absolutely through the process. I found that out. And it is really important.
Griffin Jones 1:04:48
Are all of those things in your employment agreement as the criteria for partnership track that the if it this much in volume is are those things special? To find in your employment agreement as a clause of for partnership track.
Dr. Eduardo Hariton 1:05:04
Yeah, I mean, they're, they're specified as like, once you get to X percentage of what your partners are doing. So it's not a static goal, because things change, right? Like, it doesn't mean that like, you know, that you have to hit this number, which might be meaningless in three to five years, like you signed this contract two years before starting, it's a three year partnership drag somebody places is three to five, so you don't know what they got, you know, but you know, it should be relative to what your partners are doing, because you're gonna become one of them, right? So I know that I need to hit X amount of what my partner started doing by a given time, and they'll know what they're doing, and they know what I'm doing. And they know what I need to do to get
Griffin Jones 1:05:42
there also alliance partners interests
Dr. Eduardo Hariton 1:05:45
100%. And then the other thing is, there are some times in bad economies where your base salary might be higher than what your partner started taking home. Like, you know, being an associate or being an employee is not all bad, you might not have the upside. But you also don't have the downside, guys, like, you know, if there's a bad economy, if we get a big hit your base salary comes home every day, some people like that, like, you know, partnership is not for everybody, some people want to come in come out, not worry about hiring, the worry about firing, not have the downside of a lab failure, they just check in and check out and that's okay. So there are situations where your nice cushy, associate salary might be good enough. And your partners might be taking from less than a month, you don't want to enter into that partnership at that time, because you're going to pay to take a pay cut. And that's something that you want to understand and your partners are going to want to do. And my partner said, there are situations where that might happen, we would never make your partner to have you take a pay cut. And that is a nice thing to do. So really understanding where to go and where you are is super important. And I cannot stress that enough. And if no one can give you an answer, and it's just we're just talking about it when we're three years, that seems suspect. And that's when I say talk to the people who stay talk to the people who left and get get out of their experiences, you will learn a ton from doing that.
Griffin Jones 1:07:14
There's way too much of that that happens in sales. We call it mutual mystification. It's the reason why I ended up making my sales process so rigorous sometimes over the top, but I made it really rigorous because it just that was how practices wanted to engage. They're like, Oh, yeah, you know, we'll just kind of do this. You're the guy in the red pants in the haircut. And I said, No, we have to have measurements, we have to agree that this is what's going to be required to achieve the measurements. And I want to talk about that with you the outcomes because you talked about the relationship of control to those KPIs that are necessary for partnership, I'm gonna write a book someday wardo called delegate to outcome, because I'm really figuring this out. And by the way, I have not mastered it. The reason why I am going to master it is because I've sucked so bad at it at times in my career, because it's simply not as easy as saying delegate to outcome. There's variables that affect the outcome, there's specificity, and, and, and just there's expectations. So one of these days, I'm really going to be able to I'm like, halfway there. I've I've improved so much in the last three months, because there have been people that I micromanage that never should have been micromanage. And people that I didn't fire that I should have fired in short order. And I'm figuring those things out. But when you have the outcomes they need to be they need to be specific. That's it's on the the person who's who's proposing it to say, okay, these are the outcomes that we need in exchange for this. And then what I do when I'm hiring people, as I spell out, here's what I have for you to achieve the outcomes, here's what I don't have for you to achieve the outcomes. So when we're talking about hitting IVF volumes, when we're talking about hitting certain patient numbers, we're talking about hitting a certain amount of billing and doing a certain percentage that other partners are doing, what are the factors that we have to have in our control in order to be able to achieve them?
Dr. Eduardo Hariton 1:09:21
Well, you want to make sure that you know sometimes you don't have them in your control in a way in what he says like, you want to be able to see if they pay you a new patient visit you know, can you add slots, right? Like, you know, how are they filled? Who's your marketing ended? Are you going to practices are they investing in you filling your slots? What how long is the waitlist, like if the senior partner has a two week waitlist and everybody else can feed a patient the next day or two, it's gonna be hard to get your feet you know, patient slots filled out type of thing, etc. Same thing with IVF cycles like what are the benchmarks that you need to hit to get your at risk compensation or your bonus time? sensation, and then is everybody else hitting them are all the partners hitting them, if the partners are not hitting the numbers that you need to start getting your bonus, you're probably not going to hit them. So that is that is the kind of thing you know, if you cannot near patients basics, and you can get a, you know, a controller the right way. But if you can add and work harder there to get your bonus compensations, which I would say, in most cases, you can, because they want you to work hard, they want to get the bonus, because if you're getting the bonus, it means that they are also getting some upside, right. But if there's no way to get there, and it's just a number on a page to get you to sign the contract. That's not good. So that's what I meant about kind of those control control scenarios. It's like, is it feasible to get to where they say you can get, and it's not always obvious, and you have to push and see whether everybody else got there. I also think another nice thing that I didn't mention before now that I think about it is the value of talking to people that have been through there. And I asked all the practices, like how many people have joined in the last 10 years? Where are they? How many of them are still around? What percentage of people that join as an associate become partner? You know, the best way to predict history is to learn history, right? You know, you want to see what happens to people, yes, talk to them. But if 95% of people become part there, you should feel pretty good. That's not a group of partners that are in the business of screwing people over. If 25% of people become partners, this is like an investment banking firm like it's a steep pyramid, only few are going to make it so if you're looking for your forever job, you got a one in four chance of making it to partner who knows after that, so that history is also important. There are related to control, but I wanted to drop that in.
Griffin Jones 1:11:57
Yeah, but those are really actionable things that people should be looking because I always tell people to look for the KPIs you did a good job of, of hitting on some of those things are necessary in order to be able to achieve the KPIs. What about outside of measurable KPIs like, especially with independent practices, they have to split business responsibilities among the partners. So sometimes this partner is responsible for marketing, this partner is responsible for HR, this partner is responsible for keeping the p&l this this partner is responsible for if they've they do building, if they acquire by billing. Are there other other other responsibilities that are necessary for partnerships in your agreement that aren't KPIs like that?
Dr. Eduardo Hariton 1:12:48
I mean, the other responsibilities like be part of a team. I mean, the reality is, is you will never find an agreement that forces the practice to make your partner at a given point. So, you know, I could you know, Bill more than all my partners, if I'm not a team player, if the nurses hate me, if they don't want to work with me, they have no obligation to make me a partner. And I would never expect that, like, you know, you don't marry without dating, you want to get to know someone, and some people are not the right fit. They might be nice doctors, they might be crushing productivity. But there is something about bringing you into a partnership that you need to share that ether. So yes, no one, you cannot force someone at the time of signing the contract to say if you do this, you will come a partner. Because there's a lot in between culture wise and you need to fit in there. Can that screw you? Yes, practice might say, I did everything I could I thought I was part of the thing. You always give me good feedback, year five came you're gonna sell tomorrow, you didn't make me a partner when I thought you would. Yes, and this is why the track record is really important. This is why you really want to know who you're getting in bed with an A, becoming a an associate for because they will take care of you most likely, like they took care of everybody else, you know, you feel special, you are just as special as every other area that have joined them. So really pay attention to that. But for the most part, they they can decide at the time when you get there, whether it's the right fit or not, hopefully, in the three to five years where you're an associate that will become clear so that someone doesn't string you along. If it's not the right fit. I think that's usually the case either you don't want to be there or they don't want you to be there and you part ways, but it is always up to the partners whether to make your partner or not. And I think that is the the right way because they they're bringing you into their family for long term. And they want to make sure that you're the right person for that.
Griffin Jones 1:14:46
See this. This is the light bulb going off over my head because you said that it's a place where fellows could get screwed because you can't you can't have something that's that wouldn't be in the interest of the practice to do They, that you, you are going to be a partner just because of these things. But I can think of a middle ground. And that would be a non compete, that if I hit these numbers, I'm out of my non compete the entire argument against a non compete is we invest all this money, but it's like, okay, even if we're not a good fit for partner after the fact, if I hit these numbers, my non compete doesn't stand anymore, because I've made, I've made my money for you, you see that as a potential middle ground?
Dr. Eduardo Hariton 1:15:28
You know, I've learned with talking to enough business people that I'm not an attorney, I don't know enough about these non competes. But what I will
Griffin Jones 1:15:35
say in some states are enforced in some states are not in California, you can enforce them in Texas, you can you very often, you can you certainly most places you
Dr. Eduardo Hariton 1:15:44
do have it. What I would say is like, if you are worried, like if you are joining a practice, they have a really bad track record, but they really have you and you're worried, I don't know that getting to a certain number is the right way to get out of a non compete, because they knew are very valuable in that market. But you could say something like, if you don't hit this by a given, if you hit this way, given time, and you've been this for this long, and XYZ and you're eligible for partnership, and the partners decide not to grant you that option, then you could explore having something that lets you add to your non compete, so that you don't get scared in that way. You know, again, why not go to a place that allows you to, to really feel comfortable, like, you know, it sucks to go into a job where you're like thinking every day that am I gonna get screwed at year 5am, I not gonna get screwed at year five XYZ, I hope that that's not the place that you're going to. So hopefully you join somewhere we say I trust these people, they're gonna do right by me. And over time without being worried and not get screwed on the backend.
Griffin Jones 1:16:51
Let's talk about class A's and Class B shares before you go because a lot of people don't even know what they are. So what should people be looking for? Look
Dr. Eduardo Hariton 1:17:01
with an attorney is the best advice I get, you know, Class A shares might have more control, so they have more votes. So this is a way where you know what happens with Facebook, Mark Zuckerberg controls Facebook, because he even though he doesn't own most of the company, he has like control. So not immediately obvious, you're getting shares, it's really important to understand shares of what and what you're getting. So you gotta look with them during the you got to understand that doesn't mean that there's a wrong structure if someone else has control, but at least you go in and understand what that looks like. Another thing that I talked to fellows, they're like, they gave me 500,000 shares, like, that must be amazing. I was like, 500,000, out of 10,500,000 out of 1 billion, like shares mean, nothing shares mean a part of something else, you need to understand the denominator to understand the value, you need to understand the price of the shares. And you need to understand the plan, and what you have those shares with go to. So all of these questions. This is why build fertility plane, because you don't know what questions to ask until you ask them until you learn until you see. So I hope to empower fellows with the ability to understand all of the ways in which they can get screwed all of the questions that they might need to ask, and you're not gonna be able to, like answer them yourself, you're not gonna be able to answer all of them. But my hope is that you're able to answer the majority of them use look at your blind spots, you get help. And I'm happy to talk to everybody, I do it for free I make, you know, it's, it's something that I enjoy. I do it while I drive. Hopefully it helps some people, it makes me a talk to the next generation and feel young and like a millennial, I guess they're forever fellow. I like that. But I hope it adds value. And I hope it helps people get their dream job. And I hope it helps people not get screwed. And some of them come work with their network, and it makes me happy. And some of them go work for our competitors. And that's a great job for them. And it also makes me happy. Like I have great relationships with some people at the other networks at solo practices. And now help a fellow get any job that they want. That helps them realize their career. Because this is a small field, we're all going to work together, we're all gonna see each other at conferences. And it's not about you know, I want my network to do well, but I want my field to well, and I want the areas that work so hard and got there to have a meaningful career at a place that values them. So that's why I love doing this because I truly think that it's not all about the money. It's about what you do day in and day out and you're gonna bring a nice paycheck to your kids and you don't want to get screwed in a big transaction. But ultimately, it's about getting the setup where you can be happy take care of patients and feel valued both in the environment around you and the financial rewards of your work.
Griffin Jones 1:19:50
That's a good place to conclude I've got to hit up some more of your content. I got to hit up Investopedia a little bit for just going back to basics. For a little bit, you were smart enough to have my assistant extend this time, because you knew we could go over because I can always go over with you. I could I could talk to you for another hour and a half and it would be valuable for the audience. So next time, I will be smart enough to schedule more time at a time, and I will have you back on because people will absolutely love to hear more from you. Where can people find you?
Dr. Eduardo Hariton 1:20:29
So you can Yeah, me. Everybody usually gets my fertility explained emails, you can email me@hariton.md at gmail, you can find me on Instagram, you can find me at SRM. You can email grief, and He'll put you in touch. I'm happy to chat. If it's helpful. I'm happy to send you resources. We do have a lot of our webinars taped. And I do always recommend people just spend a couple hours go through them in the car, when you're home when you're doing this is just listen, listen to the questions, listen to how all of these people in employment, etc. Think about their contracts. And if you want to chat, I'm happy to ultimately, you know, you are in a great field. You know, I've been in practice for a month and a half. So I say this humbly, like we picked a good field not only because what we get to do as doctors is incredibly satisfying, but we happen to be at a time where our field is growing. So hopefully you have a place where you can take care of your family, pursue your career vision, take care of patients and also be meaningfully rewarded for the growth that you help create and the families that you help build.
Griffin Jones 1:21:39
My good friend, Dr. Eduardo Harrison, thank you very much for coming back on inside reproductive health.
Dr. Eduardo Hariton 1:21:44
My pleasure, Griff. Thanks for having me. I look forward to seeing you. In a few weeks.
1:21:49
You You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health
