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Training & Education

224 The Best of Fertility Network C-Suite

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, nor does the Advertiser's sponsorship constitute an endorsement of the guest or their organization. The guest's appearance is not an endorsement of the Advertiser.


Since 2019, Inside Reproductive Health has conducted over 220 interviews, featuring prominent physicians and executives from numerous fertility companies.

Among them, nine CEOs continue to lead their respective Fertility Clinic Networks or chair their network’s board.

Together, their networks have overseen an estimated 1.6 million IVF cycles and other reproductive treatments that have resulted in over 2 million pregnancies,

This is an episode you don’t want to miss as we showcase:

  • Gina Bartasi and the only three things she believes matter in healthcare

  • Dave Burford sharing his battle-tested sales advice

  • TJ Farnsworth’s entrepreneurial journey and his perspective on the necessities of field wide collaboration.

  • Dr. Kshitiz Murdia’s reasoning on why doctors make good CEOs

  • Marc Segal’s perspective on private equity and its place in Fertility’s future

  • Francisco Lobbosco’s first 100 days as CEO and the power of listening

  • David Stern’s steps to finding the right financial partner (Hint: It’s like a marriage)

  • Lisa Van Dolah’s philosophy of transitioning nurses into executive leadership roles

  • Andrew Meikle discussing the power of perspective (Both patient & entrepreneur)


Dave Burford, CARE Fertility
Website

Gina Bartasi, Kindbody
Website | LinkedIn | Facebook | Instagram

Dr. Kshitiz Murdia, Indira IVF
Website | LinkedIn | Facebook | Instagram

TJ Farnsworth, Inception Fertility
Website | LinkedIn | Facebook

Francisco Lobbosco, FutureLife
Website | LinkedIn

Marc Segal, US Fertility
Website | LinkedIn | Instagram

Lisa Van Dolah, Ivy Fertility
Website | LinkedIn

David Stern, Boston IVF
Website | LinkedIn | Facebook | Instagram

Andrew Meikle, Fertility Partners
Website


Transcript

[00:00:00] Griffin Jones: Since 2019, Inside Reproductive Health has conducted roughly 230 interviews and counting featuring prominent physicians and executives from numerous fertility companies across the world. Among them, nine CEOs continue to lead their respective fertility clinic networks or chair their networks board.

Together, their networks have overseen an estimated 1. 6 million IVF cycles and other reproductive treatments that have resulted in over 2 million estimated pregnancies. 

Sponsor: This episode was brought to you by Organon, Organon is committed to championing care equity in fertility. By elevating education, expanding resources, and investing in innovative solutions, Organon stands with aspiring parents on their unique journeys. Learn more at FertilityJourney.com.

Announcer: Today’s Advertiser helped make the production and delivery of this episode possible. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, nor does the Advertiser's sponsorship constitute an endorsement of the guest or their organization. The guest's appearance is not an endorsement of the Advertiser.

[00:00:28] Kevin Ali: Hi, I'm Kevin Ali, CEO of Organon, and at Organon, we're committed to engaging with leaders across reproductive medicine. I'm proud to help introduce the best of Fertility Network's C Suite.

For the Inside Reproductive Health podcast. 

[00:00:43] Griffin Jones: Thank you, Kevin. Our best of reel begins with the CEO of Inception Fertility and the Prelude Network, TJ Farnsworth's vision emphasizes the power of collaboration among networks and clinics to advance the fertility field. 

[01:00:00]Now you're at the head of one of the largest fertility networks in the Western world, and it didn't exist five years ago, and so talk about that speed. 

[00:01:07] TJ Farnsworth: Yeah, so I think that, you know, we opened our very first practice from scratch. We didn't want to inherit, you know, ideas, not that ideas from established practices are bad. We've got some fantastic practices as part of our network that have been around for 20, 25, 30 plus years that bring a ton to the table.

But we wanted the opportunity to be able to experiment with things and ask the questions of why are things being done the way they are? And the answer being that's just the way they're done is always a bad answer. There may be a lot of great answers, but that's just the way it's always been done is never a good one.

So That allowed us to challenge what we can do and experiment. And then we also have the, we look at it as the best of both worlds. And then we have practices as part of Zora Network that have been around for, you know, with Eastern Fertility Specialists in Houston, which was our first acquisition practice.

They've been around for 25 plus years, you know, to the President's Network with RBA and TSC and NYU, bring a ton to the table. And the idea that we can bring the knowledge base From all of these places, people that are challenging the norm and saying, why can't we do things differently with de novo development from scratch operations to establish practices that have been doing it in such a way that really does work and those work for a really great reason.

And that way we can take the best of all worlds and combine them together. It's sort of been a unique approach. To how we grow the business, it's allowed us to grow into, you pointed out, you know, one of the largest networks in the world, and we're very proud of that. And mostly we're very proud of the fact that the way it came together, because it came together in such a way that lots of different people bring a lot of really great talents, really great experiences and really great processes to the table that we can blend to create the best of all worlds.

I'd love to see a whole lot more collaboration with our industry. You know, I think that coming out of a different specialty, I am surprised at all a return at how the lack of collaboration that exists between all of the big national networks and the independent practices in terms of sharing best practices, what can we be doing to make them successful?

You know, to the extent that the other national networks are successful to the extent that other independent practices are successful. That's good for me. That's good for inception. That's good for all of us as an industry. We want to see people be successful. And you know, we need to focus less on our competition amongst ourselves and more on our customer as our patient.

And that can be done through greater collaboration. 

[00:03:39] Griffin Jones: Rather than dictating from the top, our next guest engaged with staff across all levels, gathering insights to guide future life's growth. Hear how Francisco Lobbosco spent his first 100 days as CEO of FutureLife. 

So that leads you after your 100 days to recommend changes, and you said that they accepted all of the changes you proposed. What were they? 

[00:04:01] Francisco Lobbosco: So listen, so I went on by having, let's say, Um, one strong mandate, which was not imposed by anyone, but I could read it through my first a hundred days. Future life from a medical perspective is very well positioned and our medical outcomes are it. Fantastic. Francisco. Now you know that don't touch that.

Right? So let's, let's make sure that whatever you do, you don't mess up with the medical excellence that we're having in the business because that is what describes us. But then I went on and said, okay, so one of the things I'm asking is why are you here? And I'm getting different, different views, all great views, all great answers.

Um, and especially when I go around clinics, the purpose is there. What I was missing was this little trick on asking the same question around support center and saying, why are you guys here? And perhaps we were missing that, you know, to verbalize the, the purpose, the mission, the vision, the values of importantly, the values of future life.

So I went on and asked, why are we here? And then I went on and asked, what are we, uh, what are we setting ourselves to achieve? I, what our strategy is going to be in the next five years. And then finally, how are we going to. You know, just go through that strategy. So the why, the what, and the how. Um, so quite simply after my 100 days, the first thing I did is to grab, um, collect a number of associates across clinics, different roles, support center, different roles.

And we set ourselves with support of a, um, of an agency to define the future life purpose. Why is future life here? What's our vision of the world? What's our mission? And most importantly, what are our values? Um, and obviously we have clinics, as I said to you, that were quite independent and they are still independent for many years, very successfully.

And some of those clinics have strong statements in place. And my purpose is not to, my mission is not to change those statements. But to have a united voice on future life and why is future life here to, to, to drive that core identity. So we've done that. And actually, I'm not sure when, when this podcast is going to go live, but I'm flying to Barcelona tomorrow to the first global leadership summit, where we're going to introduce those.

Those statements to everyone, to all our leaders in clinics. And then obviously we're going to introduce the strategy. And the strategy, as you can imagine, is something that together with my management team, tapping into the medical advisory board, tapping into some key opinion leaders from country, we developed and we put on a paper.

And that strategy went through my supervisory board, of course, in June, and that was approved. And now we're going to introduce you, introduce a strategy into, into the FutureLife Society again at the end of this week. Um, and that is how we're going to go through that strategy and what is important for us to achieve.

And this question of why do we have a group? What is group going to do different than the clinics we're doing until now independently? That's a very important question that needs answering quite fast. Um, the synergies that we'll have a group. Those roles and responsibilities between, okay, clinics are doing this, fantastic.

How can groups support the clinics on, on being better at that, you know, at that quality of care? How can we help the clinicians in particular, the, the EMTs, the embryologists, the nurses to have more time with patients? Instead of having, you know, non value added activities or non value added time. So that's the purpose of group.

And that's what we're setting here to, to, uh, to achieve through the how. And finally, and with this I finish, um, it's all about, as I said earlier, to keeping that medical excellence in place. And therefore we introduced. Literally two months ago, our medical advisory board to the CEO, uh, which are 10 of our 10 of our great, uh, associates, you know, medical doctors, embryologists.

Um, and we'll get together once a month, um, and they have three different topics in the agenda that they need to help us, um, drive just as a final thought from my end, which is something I said to my team quite often. Um, I know that people like you Griffin, most of your listeners, if not all have been, have been in this sector in this space for, for quite some time.

And you're very familiar with it. Um, but sometimes it's good to have someone external timing, uh, reminding On how powerful it is to work that you guys do on a daily basis. And I'm talking about everyone working in clinics, right? So um, this goes for everyone working in a clinic, MDs, embryologists, nurses, receptionists, coordinators.

It's just fascinating what you guys do on a daily basis. I mean, your job is to put smiles on people's faces. Um, so my last words would be encouraging you to continue going. Um, I think what you're doing helps the sector in particular Griffin, uh, and for everyone else out there, just, just keep going. I think, um, we, or you in particular, uh, are changing the world one baby at a time.

So big thank you from my end. 

[00:09:16] Griffin Jones: Boston IVF says that in order to take good care of patients, you have to have a business model that takes good care of their providers and staff. Listen to David Stern discuss the vital steps to finding the right long term financial partner. 

[00:09:28] David Stern: And you know, one of the important things, it sounds a little corny, um, but the Boston IVF, our model is we want to do what's right for the patient first and foremost.

So we believe, and this is instilled because the physicians founded the practice and I'm not a physician, I'm an MBA, but I can tell you, I don't mess with the lab and I don't mess with the physicians. because those are the two most important assets that we have in our company. And I'm never going to tell an embryologist if they want to use a certain media and they want to use a certain microscope or an incubator because they get better success rates.

It's in my interest as a business person to make sure we get the best success rates that we can because our patients are going to be happy. Our referring physicians are going to be happy. Everybody's going to be happy. So I'm not going to cut corners and say, Hey, I got a great deal on this media. From A, B, C media factory, and it's not the same quality as Irvine or Cooper, but you gotta use it because we're saving money.

Same thing with catheters. We have physicians that choose different catheters. We don't have one catheter. We let the physician who's doing the transfer use the catheter they feel comfortable with. It costs us more, but the physician feels like they're doing a better transfer and they're more comfortable doing it.

So who am I as a business person to tell a physician how to practice or an embryologist how to practice? When you're dating someone, your first date is not about getting married. You have to date someone, see if it's a right fit and then get married. And I think we approach it the same way. We want to date our practices that we're going to partner with, see if it's a good fit, see if the culture is right.

See if we have, you know, commonality and an IVF center that's being approached by anybody, a strategic, a private equity, venture capital, whoever. Should be doing the same kind of due diligence. Is there a cultural fit? Do you agree on what the midterm and long term goals should be? Where do you see yourselves in five years?

And having a very open discussion about what that looks like and, and talking about who makes the decision. Does business trump medicine or does medicine trump business? And those are important discussions to have before, you know, on those dates, um, before you get married. I was, you know, with COVID, we've gone out and it's very important.

We go out and we do site visits. We want to look at the IVF center. We want to talk to the physicians. We sit down with them. I can't tell you the number of deals that we haven't won, where the other party that wins has never set foot in an IVF center that they're buying. They've never met the physician face to face.

It's all been on Zoom and they do a video tour. And if I'm spending that kind of money, Now, granted when private equity is doing it, it's not their money. It's someone else's money, but it's kind of like going in to buy a house and doing it on a Zoom video and never walking in that house. That's kind of scary.

Um, and so if a physician, if I'm a physician selling my practice and I never get to meet the person and they never come to see what my practice looks like, I would think long and hard about, are they the right partner for me?

Sponsor: Organon is dedicated to delivering impactful medicines and solutions for a healthier tomorrow. Guided by its mission of being here for her health, Organon proudly recognizes fertility providers around the world focusing on care equity. 

We believe everyone should have access to fertility education and treatment. By collaborating with providers, advocates, and communities, Organon is working to elevate fertility awareness, expand resources, and invest in innovative products that help more aspiring parents access the care they deserve. 

Every journey to parenthood is unique. Organon stands with you. Learn more about Organon’s resources at FertilityJourney.com

[00:12:39] Griffin Jones: Here, Chairman of U. S. Fertility, Mark Segal, delve into the enduring presence of private equity in the fertility sector, emphasizing the significance of aligning business goals with a genuine passion for solving critical issues in the fertility field.

[00:12:52] Marc Segal: Private equity is no question. Private equity is here to stay, right? It's not going anywhere. Um, and it will, there will [00:13:00] always be this need for capital and equity. Um, and I also, I also believe, you know, These innovative, uh, in physicians want to be something part of something larger than than themselves, right?

Um, and so finding the right fit. Yeah, is is, of course, paramount. Um, I would say that I've seen in my career again, uh, private equity. make very poor decisions and very poor business decisions and in some cases, you know, destroy practices, um, and, and, and the culture that they may have created. Uh, but I've also been very fortunate to be part of a group, be part of groups that I think have driven real value and innovation that's benefited both just both physicians and patients.

I believe, you know, the group that we are affiliated today called Amulet Capital is exactly that. I've been very, very impressed. And as I said, I've been involved with many different private equity groups. Um, I think there's this misconception about, uh, uh, that private equity, you know, what the does is.

drive down, drive costs and it's, uh, and therefore that impacts quality of medicine. I think that's a, that's actually a false. narrative. I think it's a false assumption. 

[00:14:34] Griffin Jones: You think it's false that it drives them up or because they're seeking profits or, or drives them down for efficiency? Which one of those do you think is a fallacy?

I think it's, I think 

[00:14:43] Marc Segal: it's a false narrative that, that driving down costs, driving down costs drives down quality of medicine. Um, Where I think private equity and again, maybe larger groups succeed is in the ability to drive to drive costs in an efficient through efficiency. Right. And, and, uh, and to me, driving down costs, which hopefully at the end of the day implies driving down price to patients or driving or driving access through increased payer contracts, etc.

Leads to better access to patients. And in fact, if you look at the larger groups, you look at, you look at the, you know, pregnancy rate outcomes, it completely validates the point that the larger groups are driving, driving innovation, driving pregnancy rates, doing different things that I think others are taking note of and trying to learn from.

Um, so, um, I, I do think it's, you know, at the end of the day, yes, you should do your homework and you should pick your right partner. Um, because not everyone's the same, not every private equity is the same. Um, but I, I, you know, I am a believer they're here to stay. I'm a believer, I'm a firm believer that they will, That they will continue to add value and make change in a positive way, not a negative way.

What is it that I need to do to kind of grow my, my practice? in order so I can maximize the valuation, uh, or potentially exit that type of thing. And, um, and what I think, and I would say this is actually all businesses in general, this is not specific to physicians or even healthcare, but, but, you know, when you've got, uh, when you've got a founder and entrepreneur that has started a business, it may be a family owned business,

If they are, if they start or have started having the conversation, you know, if they, if they're thinking about, I want to sell my business in a year's time, or even two years time, it's probably too late to have that to start thinking what I need to do. To maximize value, the conversation or the thought process about maximizing value has to occur much earlier on because it's part of a strategy.

It's part of a mindset, you know, of this is what I'm after. This is where I think I can build it. This is what I and so it's really to maximize value. It's a five year process. Now again, here's the calculus. Do I, do I spend, uh, do I spend the next five years building, hopefully, you know, doubling the size, tripling the size of the business that I have today and will valuations remain where they are today, right?

That's the big question. Because no one knows what tomorrow brings. No one knows what, what valuation, what interest rates and valuation and how much it's private equity will want to participate five years from now. Um, and so I think the calculus you have to make in all of this is, I'm either in it for the long term, if I'm only focused on, I want to figure out what the exit and how to maximize value so I can exit at some point, I actually think it's the wrong conversation to be having with yourself, right?

If I'm that entrepreneur, I think you've got to be driven by, you What are you trying? What problem are you trying to solve? What? What motivates you? What gets you to get up? You know, um, out of bed every morning. I want to do the kinds of things that you do. And you've got to love it. You've got to have a passion for it.

I mean, I know that I wouldn't be doing this for 25 years. If I didn't feel excited and passionate about it. 

[00:18:43] Griffin Jones: Our next leader, CEO of Care Fertility, Dave Burford, sheds light on the imperative of enhancing business processes to improve the patient experience. One of the biggest criticisms about so much external finance entering this field of medicine is the that there is a financial pressure and sometimes an oversight on operational quality.

There's operational improvements to be made for days in this field. There's, there's no shortage of those, but there is also the reality that there. It's a way of looking at things where it can be just looked at from a spreadsheet without the consideration of actually making the operational improvements.

And you had to at least experience some of the other sides. So what were a few of the surprises that awaited you? 

[00:19:37] Dave Burford: I think first and foremost, um, finance is very good on spreadsheets. Operations is very bad on PowerPoints and spreadsheets. Operations is about people and it's about process. And you only really can deal with one when you understand the other.

And so if I take us back to cares challenges at the time, it was very much around, um, a business that was geared up to, um, serve the clinic rather than the patients. And that's okay. When you've got a lot of demand and not much supply, but when, when that dynamic changes slightly and you've got more competition in town and you've got other people that are doing things in a more dynamic way, and actually.

The challenge is bringing in, um, supply or patients, then you've got to change your processes to adapt to that. And you've got to be more patient friendly and you've got to be more, um, Uh, adaptive and fluid in the way that you deal with things. And so, yeah, you can only really do that by talking to the people on the ground, talking to the staff, understanding what their challenges are, and then adapting the processes to meet the demands of patients and the needs of staff.

Um, So it was, for me, it was nice to get away from the, the laptop and the, and the, and the, and the PC and to actually talk to people and understand what is it that is the challenge here and that's best supported by a bit of data, if I'm honest as well, because sometimes anecdotal conversations only take you so far and you need to have a bit of skepticism about what you hear and then you need to look at the data and say, well, actually, look, we've got a thousand people calling us at The seven o'clock at night, you're telling me that patients don't have a demand for late night calls.

But why have I got a thousand, why have I got a thousand people ringing me when the lines are closed and it's just tweaking then some of those operational processes to meet those needs. Um, generally not that challenging, but, um, involved, yeah. Sales side device is critical and these advisors do an amazing job, but it's when it's a very fast six week process and highest bid wins kind of thing.

It might be perfect for some sellers, but in my experience, what you'll find is that there's sometimes a misalignment after the sale because you didn't really get chance to talk about what it is that you want and what it is that they want and how can you, it was a very quick, it was a very quick process.

And so this is. Quite often somebody's lifetimes work, right? They spent 20 years building this business. Why not spend a little bit longer just getting to know who it is that you're going to be partnering with after the, after the deal would be my main advice, really, to, to people. And then, as I say, my passion and, and cares passion, having done lots and lots of these acquisitions over the years is to really understand what it is that people want, uh, and then to try and tailor that deal to suit them.

[00:22:38] Griffin Jones: Dr. Kshitiz Murdia, CEO of Indira IVF's CLIPS, revolve around the importance of standardizing protocols across the entire network of doctors, emphasizing the need for consistency and quality. 

[00:22:50] Dr. Kshitiz Murdia: I think that brings me to another important point, Griffin, is around the doctor recruitment, as to how we have done it.

Because. Ours is a B2C brand and patients are coming to Indira IVF and not to a particular doctor. I mean, patients don't come with a mindset that I have to go and meet such and such doctor or get treated by such and such doctor. They just see Indira IVF, they would come to Indira IVF, and then they would get to know who is the doctor treating them.

And every other day we have a roaster, so somebody is consulting today. Their pickup might be done by a separate doctor. Their embryo transfer might be done by a separate doctor. It's as per the schedule or the roster in the clinic. Uh, so it was our responsibility to ensure that we have similar protocols, similar outcomes across all the doctors because that's what we were doing.

One patient could be meeting two or three doctors in the clinic at different points of time during the same cycle and the protocols should not differ. The language that they speak should not differ. And that's why we started this Indira Fertility Academy back in 2016, which is one of the world class setups in training in fertility.

Our training center has been recognized by, recently by British Fertility Society. Our training center is recognized by Merck Foundation in Egypt. They regularly send, uh, uh, African and Indonesian and Malaysian, Vietnam, all the Asia Pacific doctors for training. We run a fellowship program with them for three months.

And 99 percent of the doctors who are working with us, I've been trained through our own fertility academy and same with the embryologist also. And once we got a hang of it, uh, we understood that, you know, IVF is not so difficult. It's not a rocket science. You know, every gynecologist and a life science, uh, a postgraduate could be trained into either being a IVF doctor or an embryologist.

Uh, either ways. Uh, we developed a structured program and we understood that there are 15 or 20 steps during the whole IVF cycle. Once you have an SOP around each and every step, you just hammer in the training that you just need to follow the SOP. Don't bother about the final outcomes. Final outcomes are bound to come.

And we've been very successful. I think the average age of our doctors is 35 or 36 in spite of, you know, a few doctors being with us for almost 10 years now. Uh, so that gave us a very good handle on expansion because. See, expansion, the major limiting factor for any clinical enterprise or an organization to expand rapidly is not funds, it's not infrastructure.

You, everybody has deep pockets, everybody has private equity money. You can fund a hundred centers in one year. You have the infrastructure available. You can buy spaces, you can rent them, you can do. I think the critical bottleneck for any organization could be having skilled manpower, you know, and then there's always shortage of manpower in whichever field you go.

And we decided that we would not struggle with this part. Let us create our own skilled manpower and let us not depend on the market, uh, uh, to get skilled manpower. The idea was to select somebody working with the company for, for, for last few years, because. You know, when DA invested, we were only at 50 center, we were the largest in the country in terms of number of centers, in terms of doctors being trained, in terms of business and, and the overall top line.

I think the idea from DA's side was, uh, nobody has done, uh, good work in the country in India in the IVF suite apart from Indira IVF. Let us have somebody from the group internally, uh, and promote them to the, to be the CEO. And I think because of, uh, uh, some of the diligence is being done on the company before DA invested.

Uh, so there were a couple of private equities, uh, looking at us and in all the big force coming and doing diligence. So I got exposed to many more financial aspects, many more HR and marketing aspects as well. And, uh, so I think, I think it was. Because everybody, all these shareholders thought that I had a very broad based idea about the business and not just the medical function.

Uh, and, and, and obviously we are very strong believers that a medical organization should always be headed by a doctor because that gives you much more leverage. In terms of talking to the doctors, because ultimately all these, uh, businesses are built on the ground in the clinics and not sitting in the corporate office in your air conditioned chambers and working on excels or laptops or you can't build a business.

Their business is actually being done at the clinical level by the clinicians, by the nurses, by the embryologist. So you would need somebody who could have that wavelength of talking to these doctors who the doctors would also respond to and respect. Uh, and it's not just about number, number, number that you need to clock certain revenue.

You need to clock certain number of patients being treated. It's always more to do with the medical outcomes and how do you treat and how do you excel in, in the overall outcome. So I, I, I strongly still feel, uh, that a non medical person, uh, one sounds very commercial to the doctors. Uh, doctors would not give that much of respect because.

Again, they feel the other person has no knowledge about medicine and is just come here and just telling us all the numbers on Excel. And we feel it's not like that. And, you know, Patients are different. The actual clinical life is different. So I think a good balance, uh, uh, between the medical and the financial work is required when you want to control the doctors.

And when I say control, because ours is a very different culture and DNA, it's not doctors independently practicing in their own. world and they have a different protocol and they have a different business mindset. All of us, uh, all the two 50 plus doctors run on a single platform, run on a single protocol.

Everybody, uh, is, is, is in very. Close touch, I would say, and everybody's using the similar protocol.

[00:29:13] Griffin Jones: How many nurses, what percentage that you've worked with over the course of your career, which is a lot, do you think have it in them to be an executive? And do not say a hundred percent, do not say all of them. I don't want it. I want any kind of fluffy millennial feel good answer. I mean, if you work with a ton of people, ballpark, what are the percentage, uh, that you feel like really have it within them that they could be not manager, not director, but top C-suite?

[00:29:47] Lisa Van Dolah: Anybody that sets their mind out to do it can do it, but you have to be willing to, to learn, um, and step out of, uh, Kind of a comfort of a clinical based mindset. And I think, um, many nurses don't want to have anything to do with that. They went into the profession, um, to be a clinical focused expert and they should, that's amazing.

Um, and they should continue to explore that, how they can continue to contribute there. Um, you know, there's only so many individuals that went into nursing originally that then look at organizational, um, Uh, you know, goals and organizational, you know, success as being something that are even interested in, in being responsible for.

So, you know, we all can contribute at every level of nursing, um, to that organization success, whether or not you want to be the one that's. that's thinking about that 100 percent of the time is, you know, it's only an interest of certain, certain individuals. And, you know, but I don't think any nurse should limit themselves, um, to that possibility if that's something they're interested in doing.

If this is a role that you want to learn, we'll be here to support you. And so if it's something that you want As a nurse to step into something that maybe is outside of what you perceive to be your training. I think you need to seek that opportunity, um, and ask for those around you to support you, um, in learning things that maybe you don't have any experience in yet.

Um, and I think nursing, um, has tremendous foundation to offer you the skill set. Uh, in a variety of roles, whether it's administrative management, leadership, um, or, you know, like you said, project management, sales, marketing, business development, all of those things are, are, are ways training, teaching, um, for nurses to, to advance their career.

And so it's not just one path, but I think nursing has tremendous foundational, um, value that, that you can build on if you're interested in. 

[00:31:58] Griffin Jones: The three things that matter in healthcare are patient experience, patient outcome, and cost, according to our next leader, Chair of KindBody, Gina Bartasi. Here, Gina stressed the value of team collaboration and employee well being in delivering exceptional patient care.

[00:32:11] Gina Bartasi: Really? Only three things matter in healthcare? Any kind of health care, but specifically fertility, um, patient experience, patient outcome and cost. It's the only thing that matters to the patient, patient experience, patient outcome and cost. And by the way, it's the only thing that matters to the employer.

And what I have found after building and running the largest care navigation firm as a care navigation or middleman or an insurance company, um, Um, you cannot effectuate change in those three areas. An insurance company or care navigation firm cannot affect member experience. They cannot affect outcomes and they cannot affect costs.

Only the doctor's going to set his reimbursement rate. He's only going to decide how many embryos to transfer. Only he can decide how to give that patient bad news, whether that's, um, uh, diminished ovarian reserve diagnosis or a failed IVF cycle. But in order to really effectuate change. And really change kind of how patients go through the process.

You have to be in the doctor business. So today the employers are issuing RFPs. Um, I think in the beginning, uh, large tech companies on both coasts are really in the Valley kind of started this fertility benefit. But today you see requests coming in from very, very large employers in retail and manufacturing and automotive.

Like again, it's moved from kind of a nice to have to a must have benefit. Employees always come first. They have to because the employees will take care. If you take care of your employees first, they will take care of your customer. They will take care of your patients. And that's when we're talking to doctors, you know, and doctors say, well, I used to do that.

You know, we want the doctors to know that we can train and teach. nurses and front desk managers and practice managers to be just as kind and just as empathetic to that patient that the doctor can. So again, employees always come first as it relates to the lab. 

[00:34:11] Griffin Jones: Talk a bit about how you use the brand for culture.

[00:34:15] Gina Bartasi: Yeah, I think, um, a lot of it starts with humility, right? The brand is humble. It's not anybody's last name. It's not, you know, um, and our culture really starts with this humility, right? So those two things are ingrained. I think, um, it's not just humility to, it's a vulnerability to it. Um, you know, uh, It's also our brand and our culture.

We do embrace risk. You know, we tell our doctors, we're like, embrace risk, do something crazy on TikTok. Can you tell a doctor to, or a scientist embrace risk? They're like, whoa, whoa, whoa, whoa, whoa. I'm a doctor. I don't embrace risk, except that if you teach them, we're not talking about embracing risk when it comes to, a prognosis of an onco patient.

We're talking about taking risk as it relates to the brand, as it relates to culture, allow yourself to have fun, allow yourself to smile, giving devastating news. Another failed pregnancy test is hard. It's hard. And we're so glad you're empathetic to your patient. But outside of that, how can we make you smile?

How can you be cheery and yellow and optimistic? And so we believe that there's a lot of similarities that brand and culture do go together. And I don't think our brand would be as successful if our culture wasn't so strong. And I don't think our culture would be so strong if our brand wasn't so strong.

And there's a, I think the other thing that I would say about culture and brand is team. Right. Um, I think too often, you know, healthcare people and doctors in particular may think solo first, like I'm a doctor and hierarchical and solo. And those are not things that belong in our brand or our culture. We don't do anything singularly.

Not any of us. And, and Dr. Beltsos would say the same thing. And Beth Eschbach, Greg Poulos, none of us do anything by ourselves. And that's intentional. We make group collaborative decisions and same thing with our brand. It's, it's, it's, we invite feedback. We invite constructive feedback, constructive criticism, because we want to get better every day.

And again, that goes back to our brand and our culture. 

[00:36:25] Griffin Jones: Andrew Meikle, Executive Chairman at The Fertility Partners, challenges traditional paradigms as he advocates for financial awareness and entrepreneurship in clinic management. 

[00:36:33] Andrew Meikle: I think that, um, you know, the typical practice owner is not an entrepreneur, and they're not typically very business savvy.

Some are, and they're doing exceptionally well. This space has grown 10 percent compounded forever. And, and, you know, No disrespect, but almost anyone can do well in that sort of a setting, especially when supply is not meeting demand. So everyone's doing well. Um, almost everyone's doing well. I think there's another level.

It's not just about revenue and EBITDA, you know, our mission and, you know, I'm a healthcare provider at heart is to drive clinical outcomes to use science, collaborate with stakeholders and our group to, to drive clinical outcomes, to be more successful for our patients. And as well to improve, dramatically improve the patient experience, the patient journey.

So it's pretty simple. All of our decisions are made, um, You know, based on those two things. And I think there's a tremendous opportunity to professionalize some of the areas in the space. Um, when you look at, at management, for example, I think there are a lot of people doing a lot of great things, but it's, it's sort of doctor first, it's not patient first.

So we're flipping this, um, profession on its head and looking at the management and the operational efficiency and effectiveness of, of clinics. We're looking at Uh, you know, lean processing from a patient perspective. We're looking at, um, sort of value innovation from a customer perspective. It's gotta be driven by, um, by the patient.

We have to serve the patient. Um, and I, and I think it's largely the other way today. So we, we have a completely different lens and I think most groups, um, we're investing for the longterm. Um, we can get into private equity if you want. I am now. Back. We are now backed by private equity. You got to be careful who you choose, who you partner with.

You got to be careful who you marry. You got to spend time. You got to do your diligence. You got to go on dates. Um, and you have to be, um, ruthless in your due diligence because it is a life sentence. I don't know how to turn a physician into an entrepreneur per se. I think you have to have the fortitude for it.

You have to be able to delegate tremendously because you need to see everything from 60, 000 feet and not be too in the weeds. Um, I think an absolutely critical element and some Something that I see as a weakness generally in the space is a lack of, um, financial, um, awareness, a lot, a lack of operating the business, uh, with financial metrics.

Um, people in the space seem to look at it in the rear view mirror rather than in real time. You know, our organization, we provide a full P and L every month. Month by the eighth day of the next month. So our partners can see what they've done in their business and and uh, How it relates to the strap plan that we've worked on them for going forward.

Um, so I think you know We don't have enough time, but I you know, I mean a start would be Definitely start reading some, some books, you know, um, there's a ton of great information on entrepreneurship out there. Gerber has a whole series. Uh, uh, you know, those things are very helpful, but, but you really have to take yourself out of the day to day equation, be able to see it from 60, 000 feet, have the best, most independent.

You know, brightest people you can working for you, um, actually, you know, executing on things. And I think that's a big first step. There are tremendous opportunities out there to, um, to partner with various organizations if it, if it suits you. And I think it's just really important to, you know, Have your house in order before entering into that do your due diligence find the right fit um, and look this this profession right now, is it incredibly, um, is that an inflection point it is changing and If you want to change, you might, you might look to join an organization that, um, aligns with your values and they can help you.

They could support you, um, to implement changes in your clinic, to drive patient flow, to, um, to make your life easier so you can provide the best possible medicine. 

[00:40:56] Kevin Ali: In today's episode, we learned how various leaders are working to evolve the landscape of reproductive medicine. Working together, we can drive innovation to help improve the aspiring parent's experience.

I'm Kevin Ali, CEO of Organon. Thank you for listening to the Inside Reproductive Health podcast. 

Sponsor: This episode was brought to you by Organon, Organon is committed to championing care equity in fertility. By elevating education, expanding resources, and investing in innovative solutions, Organon stands with aspiring parents on their unique journeys. Learn more at FertilityJourney.com.

Announcer: Today’s Advertiser helped make the production and delivery of this episode possible. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, nor does the Advertiser's sponsorship constitute an endorsement of the guest or their organization. The guest's appearance is not an endorsement of the Advertiser.

221 How to Prepare Your Patients for Donor IVF with Dr. Mark Leondires and Lisa Schuman

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


How do you prepare your patients for donor IVF in a way that provides the personalized care they need while setting the right expectations for their future?

Dr. Mark Leondires, REI and co-founder of Illume Fertility,  tackles this question with Lisa Schuman, licensed clinical social worker and co-author of Building Your Family: The Complete Guide to Donor Conception.

Tune in as Dr. Leondires & Ms. Schuman discuss:

  • The criteria intended parents should focus on more when searching for donors (And focus on less)

  • What’s reasonable for intended parents to expect from their donors

  • What’s reasonable for donor-conceived children to expect from their donors

  • The commodification of donor sperm and donor egg

  • Speculation on how to solve the issue of 3rd Party IVF demand far outstripping the supply of carriers & donors

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Transcript

[00:00:00] Dr. Mark Leondires: I think that most people go on a donor website and they start with what this person looks like and that biases them down the pathway to accept some things. It's a, it's a complete loss of control to choose a donor. It's nothing that anybody wants to do, but there are things you can control and understand that, you know, you can make sure.

Your donor has had mental health screening and passed. There's a whole generation of sperm donors that never had mental health screening. And there are many hundreds of families that suffered the consequences of young men with mental illness who went ahead and transmitted that, some of these heritable risks onto their children.

[00:00:41] Sponsor: This episode was brought to you by BUNDL Fertility. Fertility clinics, ready to boost your online reviews? Our survey of over 2, 500 online patient reviews showed that 30 percent of the negative experiences were focused on billing or finance frustrations. Improve patient satisfaction and billing experiences by using BUNDL with Medications services.

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Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health nor of the advertiser. The advertiser does not have editorial control over the content of this episode and the guest's appearance is not an endorsement of the advertiser.

[00:01:40] Griffin Jones: How do you prepare patients for third party IVF? Preparing them in a way that grows your third party IVF program, that provides patients with the personalized care that they need, and that sets them and their children with the right expectations for their future. My guests have a new book called Building Your Family, The Complete Guide to Donor Conception.

We talk about donor egg and donor sperm. We also talk about gestational carriers. Because my guests each have deep expertise in in different areas in this realm. Dr. Mark Leondires is an REI. He's one of the founding partners of what is now Ellume Fertility and the organization Gay Parents to Be. Mark does a much higher share of third party IVF than average, and over the years he's shared many cases with Lisa Schuman, who's a licensed clinical social worker who has a lot of experience with screening candidates for mental health and properly preparing intended parents and donors so that they have true informed consent.

Mark and Lisa talk about what criteria they need to get intended parents focused on more, and what criteria they need to focus on less when they're searching for donors. With 25, 000 donor conceived siblings connected to each other in online registries, what's reasonable for intended parents to expect from donors?

and to expect from their practices and what's reasonable for donor conceived children to expect from donors and practices. Dr. Leondires talks about monetization of donor sperm and donor egg, and we speculate on what's coming in the future that might be necessary to solve for the issue of the demand for third party IVF, greatly outstripping the supply of gestational carriers, sperm donors, and egg donors.

Again, the book is called Building Your Family, The Complete Guide to Donor Conception. It's available on Amazon and other places books are sold. Enjoy this conversation with Lisa Schuman and Dr. Mark Leanderis. Ms. Schuman, Lisa, welcome to the Inside Reproductive Health podcast. Dr. Leanderis, Mark, welcome back to the Inside Reproductive Health podcast.

Thank you, Chris. Thank you. I'm. I'm interested to explore what's happening with third party IVF in the U. S. in the world. And then I'm interested to explore the book that you've written on the topic called building your family that the two of you coauthored. Let's start with just what's happening in the marketplace.

What are the numbers in terms of how much donor egg donor sperm? Gestational carrier IVF has grown in the U. S. in the last decade or, or, or some years. 

[00:04:04] Dr. Mark Leondires: Yes, Griffin, I can certainly address that. So, you know, for myself, I'll tell you that I see very few regular infertility patients anymore. My practice is almost wholly, um, donor conception.

Everything from cisgender female couples looking to conceive, to same sex male couples, to talking about people want to receive donated embryos, to people, you know, moving forward with gestational carrier cycles with donated gametes. So third party reproduction nowadays is both You know, donated sperm, donated eggs, donated embryos, and the utilization of gestational carriers.

And what we can clearly see in the SART data, and anybody can do this themselves, if you just pull the increase in the past 10 years of embryo transfers from donated eggs. That's increased by 40%. And if you also just dig into start yourself and you can watch the slope of the line of the utilization of gestational carriers go up year over year over year.

Obviously, as with most things in our field, there was a dip in during COVID, but the utilization of donated gametes has increased. And then. You know, we're not even aware of what's happening on the sperm donor world in that we've passed two of the major sources of donor sperm, and they state that demand is, is outstripping supply.

There may be some other reasons for that as well as that we talked about in the book, as far as anonymity. The other part of the story is that people are going out and finding their own donors, whether it be on Facebook, Craigslist, or a lot of these other third party sites that are trying to match people with sperm sources.

Uh, so, uh, so there's a, there's a, an openness to using donated gametes that I think is, is relatively, you know, um, new in the past 10 to 15 years. And, and there's still, and there's people who want to be parents sometimes who either biologically can't be parents because there are members of the LGBTQ plus community, or perhaps they're single.

They want to be a parent and they don't want to be. Um, held back because they, they haven't found that person or don't want to find it or last but not least, you know, there's other reasons, whether it be low sperm male factor or female factor that they're using donated gametes, but they want to be parents and, and there's lots of different ways for them to get there.

And the demand for that is increasing. 

[00:06:32] Griffin Jones: So was that, was the demand outstripping the supply? Is that part of the reason for writing the book? Tell me about why the book was written because normally when someone writes a book, it's that some monkey that they want to get off. They're back. It's either some subject matter expertise that they've developed such a unique point of view on that they want to share that unique point of view, or they find such a misconception or lack of total comprehension around a certain subject that they want to address that for you all.

What were, what was the primary reason for writing the book? 

[00:07:10] Lisa Schuman: You are right on point, Griffin. Exactly. Correct. I felt. Day after day, week after week, year after year, people would talk to me about their donor conception journey and the things that they wanted to do, whether it's how to talk to their children, how to choose a donor.

And I would share what I knew. And people would say over and over again, how come nobody's telling me these things? I can't believe this information that you're sharing. How come nobody says it? And in part I was informed by my own experience in the field and partially just watching the adoption field move over time from a place where people You know, in the fifties, there was a large number of children adopted in the U.

S. And over decades, we can see how those adopted children felt. And those agencies used to tell people, don't tell your children. And we saw the effects of those children and learned that we had to tell early and often. And I saw a very similar trend happening in donor conception. And yet no one really seemed to kind of learn from the adoption world, even though adoption is very different than donor conception.

That particular piece is. Was very similar. So both of those things were annoying at me. 

[00:08:28] Dr. Mark Leondires: We are actively kind of almost trained, my generation of reproductive endocrinologists, to tell people that, you know, you never have to tell the story to your child, because nobody's ever going to find out. 

[00:08:43] Griffin Jones: Is that really the case, Mark?

Were you told that when you were training? 

[00:08:47] Dr. Mark Leondires: When I was training for donor conception, um, in the military, it happened very, very rarely. And it was something that was kind of back to my military days. Don't ask, don't tell. We're just not going to talk about it. You're a heterosexual couple. You need to use donated sperm or egg and, and you'll never have to talk about it again.

Because back in the nineties, nobody knew that Direct to consumer marketing of DNA testing was going to allow us to find these relationships. And they thought the parent child bond was going to be negatively affected by the truth, which it's the reverse. 

[00:09:28] Griffin Jones: Maybe you're starting to answer my next question that I've been thinking about is one version of this book could have been written by a fertility specialist.

Another version of this book could have been written by a social worker. Why did this book need to be written by both a fertility specialist and a social worker? And a social worker or or vice versa. I'm not putting one in front of the why a social worker and a fertility specialist. 

[00:09:54] Lisa Schuman: Well, I think we shared Mark and I shared a lot of cases over the last decade.

And we both really saw eye to eye on so many cases that we would struggle with. And so it really made sense for us to collaborate. 

[00:10:06] Dr. Mark Leondires: So Lisa came to our practice 2017 and At that point in time, you know, I still had a, a young family. I have a donor conceived family myself, just processing what, how to speak to my children.

And Lisa has spoken to children of donor conception and processing how. You know, meeting somebody's donor might be important to choosing a donor, right? And then, you know, transitioning our anonymous program to a known program and realizing that the donors want to know where their gametes are going. At least the young women that we spoke to from our, you know, local area.

Um, so the, the impetus to write the book, you know, comes from Lisa's experience. And then. I was I lived this life, right? And then for us both together to be working closely together and appreciating what we were hearing from the parents to be and the parents after we changed our program a little bit was transformational and it and it just wasn't out there.

There's not. This type of content out there, and I think we're ready for it. 

[00:11:22] Griffin Jones: How did you each approach what you contributed? Do you did you like Mark writes a chapter? Lisa writes a chapter. Or did you sit down at a coffee shop and jam out each chapter together? How did you each contribute your different perspectives?

[00:11:39] Lisa Schuman: Well, I think it's, you know, pretty clearly you can see which parts are the social work parts, which parts are the medical parts you can see in the book and we will send you one Griffin for sure. So you'll see. 

[00:11:50] Dr. Mark Leondires: So you know, as far as the storyboards for the book, you know, it was pretty clear, you know, how does this all work, right?

And what, what, how do we need to educate our patients, our donors, and a lot of third party reproduction. is not about the medicine. It's about the people. So the, the, the book, most of the content in the book is from a mental health interpersonal relationship point of view. And, you know, I chime in with personal stories and things like that throughout the book.

The book is not a textbook. It is not a self help book. It's, it's basically an exploration of kind of a new part of our humanity. And so, The melding of like the medical plus the personal psychosocial and so on is how it happened. So, you know, chapters of the book that are medical are mostly written by me, but Lisa chimed in of like, well, people aren't going to grasp that.

You need to take that down. And I did the same thing to, to, with her. This exercise of re reading your book three, four, or five times is really quite remarkable about how to fine tune this message to intended parents, to donors, and to children, and taking care of yourself through this process, because this is art.

[00:13:17] Lisa Schuman: It's really like a how to guide. We have a very, very clear steps on how to choose a donor, which are very different than I think a lot of people would imagine, and we think it works better for most people to use this paradigm. And there are very clear ways to understand how the medical process works, there's very clear ways to hear, to understand how to talk to your children.

Really wanted to be like a how to guide. We, we both went through our own fertility journeys and we felt it was very difficult to learn everything. Even if you're in this business, it's very difficult to know what to do and to deal with the emotions involved. And so we really felt that it would be helpful for people to have a guide to shepherd them down this journey.

[00:14:03] Griffin Jones: And part of the shepherding that you're doing, as I understand, has to do with the way people choose donors. What do you hope to change about the way people are choosing donors right now? 

[00:14:15] Lisa Schuman: Well, we hope to kind of flip the script in a way. People usually find that choosing a donor naturally, even if you Have already always known that you needed a donor.

Maybe you're a single person or maybe you're a queer couple and you feel like we are accepting of it, even then it can be very dysregulating to choose the genetics for your child. This is one of the most intimate relationships of your life from a stranger. And so. People reflexively will very often choose somebody who feels familiar to them, somebody who feels comfortable, somebody who reminds them of their, you know, their brother or has the same sort of bushy eyebrows or whatever it might be.

And that's nice. And you can see that the sperm and egg banks kind of play into that. They give you celebrity lookalikes and tell you how nice this person is or show you their, you know, their, their, Profile and maybe a voice message, but those things are not heritable. And as we know in our culture, we see lots of examples of people who don't look anything like their parents or don't have anything to do with, you know, their siblings, musical talent, or their other siblings, athleticism.

So, we know that these are not heritable, so perhaps that's not the best place to start. It's nice to like your donor. You want to like your donor because you want your child to, to maybe be able to meet that person one day. You want to feel good about talking about them, but it's not the best place to start.

Best place to start is to try to be practical and start with the more practical aspects first. And then, once that's settled and you. can decide on the practical aspects to give you the best health possible for your child, then everything else is gravy. 

[00:16:00] Dr. Mark Leondires: I think that most people go on a donor website and they start with what this person looks like.

And that biases them down the pathway to accept some things. But when you, it's a, it's a complete loss of control to choose a donor. It's nothing that anybody wants to do, but there are things you can control, right? And understand that, you know, you can make sure. Your donor has had mental health screening and there's a whole generation of sperm donors that never had mental health screening.

And there are many hundreds of families that suffered the consequences of young men with mental illness who went ahead and transmitted that some of these heritable risks onto their children. I mean, it was on the cover of the New York Times, right? Somebody with schizophrenia who's generated, you know, more than 50, 50 offspring, right?

They're they're so mental health screening for sperm donors is actually relatively new in the past five years, right? mental health screening for egg donors is has always been recommended for the asrm and it needs to continue to be done and so you can control the whether your donors passes mental screening and presents as a At a clinical interview that they're they are of sound mind and know what they're getting into and understand That they have There's a strong likelihood somebody's going to contact them in the future, that anonymity is gone and they have an ongoing responsibility to the, the, the child to be, the family and so on.

I mean, The 2019, you know, past term ethics committee on, you know, donors and donor conceptions. Their comment reads like this, and I have it up because I think it's important and really well written. Donors, recipients, and programs must recognize that they have a unique and ongoing moral relationship with each other.

And this obligation does not end. and with the procurement of gametes or the donation of embryos. Evolving medical technology, laws, and social standards will likely require re evaluation of these relationships throughout the lifetimes of the parties involved. So we'll unpack that a little bit more a little bit, maybe a little bit later on, but this is an ongoing relationship.

And I think that donors didn't always understand that or wasn't always driven home and maybe not always driven home by the medical providers that were interviewing them. So mental health screening, clinical interview and family history. Listen, when you're choosing a donor, you're not getting them.

You're not getting their picture, who they are. You're getting their family tree, probably their past three to five generations, understanding that when somebody sees a donor that they like. They should pass that to the side and go right to their family tree and then genetics. Like we all know there's recessive genes that cause disease, right?

So that needs to, that's something you can control and make sure it was done that you did it yourself. And then also think about the things that in your own family tree that you don't want to. replicate or increase risk off because we all have things in our, our genetic closet. So if you start basically with those four issues that the donor's looks and her there, because it's a male sperm and egg donors, right there, what you see becomes less important.

So one of the goals of the book is to, to, for intended parents to give them a sense of what they can control. And to, to reframe how people go about choosing donors. And I think it's also a message out there for. Providers for mental health professionals, for nurses, for everybody out there in this industry.

So we're in this industry of, of basically procuring gametes. So people could have babies, but we're, these gametes eventually become people, people with lives who have questions and so on. So we want to make sure that, that the intended parents are really thoughtful about how they choose a donor. And And of course, everybody's going to say, well, I didn't just choose a donor because of what they looked like, understanding that if you exercise as much control over the first four things I mentioned, you're going to have a really nice story to tell your child about why you chose that.

So I think that, you know, that's a big part of the book, changing the conversation on it. How people find their donors and the other parts of the book that I think are really powerful are, you know, how to talk to your children as well. 

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[00:22:07] Griffin Jones: So you're steering people away from first looking at, uh, attributes of appearance and you're steering them to more practical criteria such as, uh, their, their mental health screening, their clinical interviews, their family history. As a marketer over the years, I have learned that the market gets what the market wants.

And uh, that's not always a great thing, uh, because people don't always want things that are the best for them. They don't want. They don't always want things that are ethical. They don't always want things that are sustainable. And so if one is going to try to go against the market, they got to find a niche that's receptive enough to it.

They, and they have to find a way of leveraging that message to where people start to see something else that they want more. So how are you doing this in this chapter, in this part of the book, where you're, where you're trying to get people like, no, no, I want, you know, I want, you know, six feet tall. I want Harvard educated.

I want blue eyes and red hair. You know, how are you, how are you getting people to think differently? 

[00:23:16] Lisa Schuman: Well, a couple of things. First of all, I mean, if you give examples, I mean, even in our culture, right? The two princes of England look very different from each other. Our ex president Bill Clinton was a Rhodes scholar, president of United States and his brother is an alcoholic, right?

So people are not like their siblings, but also if you think about it. Our paradigm, instead of just the way that we reflexively think about things because we're anxious, really that's where it's coming from. We're anxious about choosing somebody we don't know, right? So we want something familiar. And I think when people understand that, they can be a little bit more reasonable about their decision.

Also, it narrows their choices. Patients often come to Mark and I saying, I feel completely overwhelmed. I'm looking at this sea of like Match. com people. I don't even know where to start, right? So if you start with, did they have mental health screening? Right away, you're narrowing the pool. Do we have replicated risks?

You're narrowing the pool. All of a sudden, you're narrowing the pool and it makes the whole process so much easier. Also, I think that, you know, we do make the point of, Why all of these things are important, we were, Mark and I were just talking before this podcast, that someone suggested to me that one of these people who's pushing for legislation that clinics should investigate all donors and do thorough background checks on them in order to prevent mental health problems of one of the families who unfortunately lost their son.

Sun through suicide is one of the people who's doing this. Unfortunately, that, I think, is, is sadly unreasonable. First of all, no clinic has the ability to do that. Secondly, it's not feasible. You can't find every single person's, every doctor appointment, every time they went to mental health counseling, every time they were prescribed everything.

And last, No one is, has a record unless they're convicted in this country. So you could have people who are mentally ill, who are, who are doing all kinds of things, and if they don't, if they're not convicted, there's no record. So what's really the point in doing all of that, when you can just do mental health screening and get a much better picture of that person?

So we, we try to make reasonable arguments for all of our suggestions. 

[00:25:25] Dr. Mark Leondires: And specifically addressing your question, how we hope to change hearts and minds is by thinking about the fact that as a parent, someday, you're going to do all these other things that are uncomfortable that you don't want to do. So your, your parenting is going to start by trying to find the best family tree, genetics, story, mental health screen donor.

Of course, they're going to be appealing to your eye. That is not what your kid's going to care about. And what do we want for our children? We want them to be healthy first, have good emotional well being, to find happiness and love and live their lives, and to be smart enough to leave your house, right?

So, so, and that's, none of that's how we traditionally find donors. So changing hearts and minds is like, Also thinking about, you know, how, why did you choose your donor conversation with your child? And it's a, it's a, it's a conversation that's developed over years. And I mean, I will tell us, I tell a story that just happened recently to me.

So we're driving back from a family event with my two kids and I have a 12 year old and a 10 year old and we're talking about the donor because I always called, um, her the donor and, and discussing that she might have her own children right now. And, and my 12 year old said, well, that means I might have a sister.

I said, yeah. And he said, that could be cool. And. My nine year old who's usually a little bit thoughtful is just hanging out back there. And so I asked, you know, what do you, what do you think about this special lady who gave us some of her cells? And then I said, you know, what should we call her? I think she needs a better name than the donor.

And he paused and said, our fairy godmother, which for me, that's kind of what these people are. They're giving us this human magic that allows us to have families. So being really thoughtful in choosing the donor is also going to be make for very strong relationship and bond and ability to talk about with your children why they chose their donor.

And that hopefully means that they're launched into adulthood with a good sense of self. That they were very much wanted and loved before they even came into existence. I mean, right now there's in the New York times this week, there was a story about donor conception. There's a popular book right now that talks about finding out, you know, my genetics are not my genetics.

At most recently at the SREI conference, which some of the listeners went to, there was a very heartfelt video about somebody who found out that, that later in life, Who they thought they were the whole time is not who they were. So how to change hearts and minds is that you're going to do this for your child to be, because you already look so like within the book, you know, changing the paradigm, getting that message out that anonymity is gone, doesn't exist anymore.

And with more openness. hopefully comes to a better place for all these families to be. And it is something that our field, I think culturally needs to change. I mean, at this same SREI conference in the 1950s, people were like the donor there, it did not matter. It wasn't something that was going to be revealed about choosing if you use donor conception.

And, and now, you know, there's a whole bunch of donor conceived people. We have a voiced, there's 25, 000 donor conceived siblings that have been connected on donor signaling registry. And these taking care of taking what we know now and, and moving it forward for the thousands of people, hundreds of thousands of people in the future who will proceed with donor conception is one of the reasons we wrote the book.

[00:29:51] Griffin Jones: Do you talk about what's reasonable to expect from donors from the part of I guess donors and providers from the part of the intended parents and from the part of the the Children of the donor of donor assisted reproductive technology. I think you were talking a little bit about that, Lisa, but I members at ASRM this year, there was a small crowd, 10, 20 people at most outside.

I don't know what their grievances were, so I don't want to misrepresent what their grievances were. I've also had Igor Brussel on this program who is an embryologist turned reproductive health attorney. And he said, Some of what is being asked for by some people from the donor conceived community in certain legislation is things that we would never be able to get from our biological parents.

And, and so it's, it isn't reasonable to ask for, for those, those things. It isn't tenable to ask for them. So do you talk about that all in the book? What, what's the limits that intended parents and children can expect from donors and providers? 

[00:30:59] Lisa Schuman: There are a lot of limits and that's a whole other conversation because there is some division, I think, between people who are donor conceived and what we find is either found out about their origins accidentally or found out late.

And those adults are usually very distraught over that. So there's, there seems to be a division between those people and then the younger donor conceived people who seem to feel a little bit better adjusted. And so there's a lot of difficulties, I think, as time goes on, as there was similarly in the adoption community until things change.

So, and we don't really go into that in the book, but we're really talking about is when you're going through fertility treatment, you have to make all of these big decisions and you're really focused on getting pregnant naturally, right? That's what everybody's focused on. Let me make a lot of embryos because I want to have as many embryos as possible.

I need to build my family. I need to get pregnant. And understandably, The patients, the doctors, everybody's kind of focused on that. And yet now we really have to think into the future. We really need to talk to the donors about what the implications are for their future. These people will reach out to them.

What's it going to mean for them? What's it going to mean for their family? What's it going to mean for their future partners? What's it going to mean for the children and for the recipients? Do they, do they really understand what they're getting into? And. it's really important for them to think wisely about all of these pieces of the puzzle before they do.

So we're really helping the people who are just beginning this process. 

[00:32:33] Griffin Jones: So what, what is it that fertility practices need to know about the changes in donor conception? 

[00:32:39] Lisa Schuman: Well, the fertility practices really need to start to think a little bit differently, right? We're, we're all kind of conditioned to think about pregnancy.

That's what we're thinking about, a happy pregnancy, and that's wonderful, but we now have to think into the future, right? Just like the ASRM, ASRM statement says, we're, we're all part of making this happen, and so we all have a responsibility to really think about What, what we're doing, how are we talking to the donors?

Do they really, are they really well informed? Do they have true informed consent in a way that's different than what we were trained to do decades ago? Are the recipients really educated about how to talk to their children? And do they really understand what that means? And, you know, as we move forward, There are a lot of donor related siblings.

You know, last year there was an, you know, a live birth from a 31-year-old embryo. So we have many, many generations of donor related siblings that are going to be coming around decade after decade, and that's not going to stop anytime soon. So we really need to be thoughtful about all of these things and prepare for the future, not just for getting pregnant.

[00:33:50] Dr. Mark Leondires: Yeah. I mean, I think that fertility clinics need to know that anybody who's thinking of donor conception needs to understand that there's, there's no way to keep things anonymous. I think that if you're speaking to any donor, whether it be a sperm donor or egg donor, that They need to be aware of that.

The other part of the story is that moving towards openness, whether it be an open egg source or open or a familial or family member or friend, the legal aspects of this are, are, are important. So, you know, in all, in, in this whole third party reproduction field, it's clinicians, doctors, nurses, embryologists, It's mental health professionals and it's reproductive attorneys that all need to work together to protect the donor's rights, the parent's rights, and the children's rights.

And it's, and it, it's just a lot more complicated than just getting somebody pregnant. It's thinking of the, the, the longterm implications. Of what we do. And so I think, you know, changing the way fertility practice thinks about, well, we're just going to help her get, help them get pregnant. It needs to needs to go to, well, we need to be really thoughtful about making sure everybody's properly educated and that they have, they understand all aspects of, you know, how donor conception through a fertility practice affects these families to be.

[00:35:26] Griffin Jones: The first time I had you on the show, Mark, was because I have so many people in the audience that want to do more third party IVF. They want to attract more gay male couples. They, they want to do more donor IVF and more GC IVF, but it's, it's not just as simple as just saying, Hey, we do this too. There's an infrastructure, there's an investment that needs to be made.

And you've invested a lot in this. And so talk to me more about the specifics of when you say, Hey, That it's, it's the docs, the nurses, embryologists and the mental health professionals working together. What does that look like specifically? 

[00:36:05] Dr. Mark Leondires: You know, I think that the third party team at every fertility practice needs to really have a very strong kind of interdisciplinary band, meaning that, you know, it's easy for you to speak to your, a reproductive attorney or Mental health professional and, and I think that, you know, our, our field is a lot of aspects of our field are being commoditized sperm and egg included and, and understanding that, that the third party team is, it's so much more than you just need a donor.

It's, you need, you need to think forwards and backwards and, and try to guide people to make their, their best decision. So as people go, want to do more and more third party, I think it's really important that there, there's a separate part of a practice or a dedicated team. That, that, that moves under stays up to date and understands what's happening in the field.

I mean, there's a beautiful conference that it's the donor egg conference that happens every year. That's, uh, it's basically all dedicated to the legal, medical, mental health aspects of donor conception. Right. And, and I think that if people want to. You know, grow this aspect of their practice, understand that it's, it's, there's a lot to it and they need to be able to pick up the phone and ask questions and, and stay up to date with what's changed because a lot has changed.

[00:37:34] Lisa Schuman: And you also, we also need to understand And, you know, Mark and I spend a lot of time talking about difficult situations with known donors. As time goes forward, more and more people are going to use their friends or family members as donors. And certainly you have people in the trans community who are going to have more and more children.

We've had people who are in throuples. And so, you know, it's only going to get more complicated and there are, you know, educational pieces that really need to be part of this practice. To help the patients understand and work through all the potential difficulties and implications for these these situations and There are a lot of ethical issues that that arise in each one of them and we have to really be thoughtful about that 

[00:38:22] Griffin Jones: You mentioned mark that we're starting to see a bit of commoditization Happening sperm and egg included that brings me back to a thread you pulled at in the beginning of this conversation about the supply and demand and that You The demand is outweighing the supply of available donors, gestational carriers.

So would commoditization possibly be a good thing that you have more of a scale to provide the supply for the demand, or is it a bad thing? 

[00:38:52] Dr. Mark Leondires: I actually think that with driving home to donors, the loss of anonymity, There, they, there may be fewer sperm donors, probably not fewer egg donors, right? There's much more greater demand for sperm donors than egg donors because the young men who were donating sperm.

I think, you know, 10, 15 years ago, didn't think that they, there was any future implications for them. And I think that, so what we've seen over the years is the compensation for donors has gone up and up and up, and the cost for donor sperm has gone up and up and up. Compensation for surrogates has gone up and up and up.

So I think that, you know, what's, I think commoditization is not going to, is not going to increase availability because the, the humans involved are, are getting a, getting a better understanding of what the, the commitment and they're not just donating, they're just donating their sperm. You know, if we're doing our job right, they understand that they're, they're helping a family come to life at, and you know, there's, there's, you know, a future child that may come knocking on their door.

And, you know, for the, for the, the, the sperm donors who were doing, you know, had the best intentions, most likely who ended up having a hundred children out there, you know, that's not, that's not something I think, you know, was done well. I can't imagine being that young person who realizes that, you know, I have, you know, 99 half siblings, nevermind the.

The, you know, 40 year old man who realizes that he has all those, you know, genetically linked children out there. So thank things are changing. 

[00:40:38] Griffin Jones: So and some of that probably some of that absolutely needs to happen because we consider us as a species. If I, if I have my statistics right, we have twice as many.

female ancestors as we do male ancestors, meaning that some men were reproducing a lot. Some men weren't reproducing at all, which tends to be common among species. And so you might have people a few decades ago that there was a Prado's distribution where you had some sperm donors donating too much, but you also might now have just because you are more properly informing donors.

Of what the involvement in the commitment is, is, as you stated earlier in the conversation, I think it is, you called it an ongoing ethical relationship between donors, recipients and the program. And so as you start to give people the proper informed consent, it becomes harder to recruit than if there's no strings attached, which is necessary.

But then how do you amplify Recruitment. 

[00:41:45] Lisa Schuman: I think they're more known donors now as a result of it. I think that's just going to happen. What do you think, Mark? 

[00:41:53] Dr. Mark Leondires: Yeah, I think that I think no donation is going to come into the forefront. And then and you know, as long as it's done well and With full disclosure and the right legal documentations, it's, it should limit the amount of families that are made from any particular sperm source.

And we already advise egg donors not to donate more than six times, but it, it, it likely will limit that. So. You know the the governor so to speak on on donor conception is likely going to be the donors themselves I don't know lisa. What do you think about that? 

[00:42:30] Lisa Schuman: Yeah, I mean, I think it's it's very important, you know decades ago I don't know if you remember but decades ago there was a an article written by a mental health professional in fertility and sterility about Uh, clinic where they had this ethical dilemma where they cycled two, two families who use the same sperm donor and the same egg donor by sheer coincidence in a very small town in Westchester in New York.

So these two little kids were born around the same time in the small town, probably, you know, went to kindergarten together and hopefully they won't go to prom together. This is, you know, a problem. So people really need to understand even the, the, you know, the limits that we have are very large. 

[00:43:13] Dr. Mark Leondires: And I just want to dial back.

It's not that, that Mark had that statement. It's the American society for reproductive medicine ethics committee that has, we have this ongoing relationship or a commitment and moral obligation. So. But I think that, 

[00:43:29] Griffin Jones: so what do we do to get more donors though? Because it sounds like that's the, that seems to be pretty common across the board, not enough gestational carriers, not enough sperm donors, not enough egg donors, and the U S is sitting in a lot better of a position than a lot of. There's there's none or very few in their countries. So what are we, what needs to happen in order to have more donors and more gestational carriers? 

[00:43:56] Dr. Mark Leondires: Well, first of all, a lot of the reasons why there's no donors in other countries is not considered legal, for those things. 

[00:44:03] Griffin Jones: And they can't compensate, and even in the countries like Australia and New Zealand, where Canada, where, where it is legal there, there's You know, there's, there's rules and limits on compensation.

So is the answer only more compensation? Is it, is it more, is it public awareness? Is it some, some change in the messaging? And if so, what does the message need to be? 

[00:44:25] Dr. Mark Leondires: I don't have a clear answer to how to solve that, that equation of supply and demand. My, my impression is that there's not going to be as much supply because of the donors.

And practices and intended parents understanding, you know, this process better, you know, the future of this may be the future of science where we're able to take stem cells and make them into sperm and egg. And then nobody needs a donor anymore. Right. Right. And so, so that will solve that problem. Uh, and then, you know, this whole industry goes, which is kind of an interesting comment for your show, right?

[00:45:10] Griffin Jones: They're, they're, they're working on it. I saw, I saw the CEO of one such company speak on that earlier this year. And, uh, maybe we'll have to have that person on the show because maybe that is ultimately the only solution. Maybe there isn't enough supply from. From from what we currently have right now, but I think that also points to the importance of what you're discussing earlier in the show in terms of preparing intended parents to look for the right things that at least they're not wasting their potential supply source by looking at things that are either superficial or just simply not as important as the practical criteria that is.

[00:45:53] Lisa Schuman: Yeah. And one other thing, Griffin, that that might might also be in the interim happening in the interim. Mark and I talk about this as part of a talk that we give. There are all of these new small companies. You're probably familiar with them like Modemily and a lot of other groups that are developing.

And I think there is this ongoing need for more transparency. And as the The donors, and I spoke about this at the egg donor conference as a donor, start to feel a greater sense of agency, maybe more power in the relationship, more interest in choosing maybe their recipients. There'll be more matchmaking companies perhaps where people will decide, maybe I want to donate.

And I have actually on my podcast, a couple of donors like this who decided they wanted to donate to specific people where they could have an open relationship and they meet people they like and they, and that. that's really the end of the story for them. So there may be more of those sorts of relationships that will develop over time.

Of course, that's a smaller number than the large sperm banks provide, but there may be a rise in that over time until we come up with the science to, to make children from stem cells. 

[00:47:03] Griffin Jones: I think it's useful for providers to pick up a copy of your book and not just providers, we also have nurses, we have practice owners, we have business suite folks that listen, we have reproductive health attorneys, we have mental health professionals that listen, people that work in our field, anyone that touches third party IVF, I think could benefit from reading your book.

Each of you have a concluding thought of what you would like. Folks that work in the fertility field to take away from your book. 

[00:47:35] Dr. Mark Leondires: So more for myself, you know, I think that understanding moving forward with recommending your patient pursued donor conception needs to then. Be followed through with making sure they understand, you know, how to choose a donor, maybe reasons to think about an open donation and what is the best and how to talk to their child and their feet in the future.

So they are, they fully know. That their parents did everything they could to bring them to life as a happy, healthy, well adjusted person. And that will not only bring these parents to be joy, but it also will bring that child to adulthood and, and hopefully as a committed, helpful member of society. 

[00:48:31] Lisa Schuman: Yes, I echo that completely and I hope that patients don't feel discouraged.

We know how stressful fertility treatment can be even when you don't have infertility and we want patients to feel like this is all possible. There are paths to parenthood that can work and you can learn these things and you should be armed with this knowledge and feel confident that you can move forward and create the family that you want to create.

[00:48:55] Griffin Jones: The book is called building your family the complete guide to donor conceptions 

The authors are dr. Markley and dearest and lisa schuman We will link to links that people can pick up the book But if they're driving in the car right now and for them to remember later on where can they pick up the book?

[00:49:15] Dr. Mark Leondires: The book is available at Amazon, Barnes and Noble and Macmillan Press. And it's also as an audio book. And, and I, I really want to thank you for having us on and, and appreciate your podcast and the work you do. And this is a very multidisciplinary podcast. So there's, there's a lot that you do for our industry.

So thank you so much. 

[00:49:36] Lisa Schuman: We really appreciate it, Griffin. 

[00:49:37] Dr. Mark Leondires: Thank you. 

[00:49:37] Griffin Jones: Thank you both for coming on. 

[00:49:39] Sponsor: This episode was brought to you by BUNDL Fertility. Fertility clinics, ready to boost your online reviews? Our survey of over 2, 500 online patient reviews showed that 30 percent of the negative experiences were focused on billing or finance frustrations.

Improve patient satisfaction and billing experiences by using BUNDL with Medications services. See the rest of our survey results by visiting www.bundlfertility.com/irh and downloading our exclusive report. 

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you, but the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser. Thank you for listening to Inside Reproductive Health.

219 Considerations for REI Fellows' Career Design with Dr. Morgan Wilhoite

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


What trends are young REI doctors interested in?

What do fertility practices need to consider when recruiting first year Fellows?

Dr. Morgan Wilhoite, a first-year REI Fellow, provides insight into her career focus and how she's shaping her Fellowship experience to align with her goals.

With Dr. Wilhoite we discuss:

  • Her areas of learning interest during Fellowship (Valuable for clinics to see the trends for young REIs)

  • The resources that all Fellows should be consuming to prepare for their ideal careers

  • Why Privademic might become the default model for young REI career preferences

  • Advice for clinics looking to recruit young fertility doctors (How to be ahead of the hiring curve)


Dr. Morgan Wilhoite
Instagram

Transcript

[00:00:00] Dr. Morgan Wilhoite: So it's almost like when you are in kindergarten and you look at the fourth graders and you're like looking at what they're wearing and what they're doing. And it's like, I want to be like them one day. That's kind of how the first year fellows I feel like are, are treating this process. We're looking at the third years who are, again, I'll use my analogy, the bells of the ball.

They're getting recruited, they're getting job offers, they're signing contracts. It's super exciting. You're living kind of vicariously through them. 

[00:00:26] Sponsor: This episode was brought to you by Prelude Fertility, where top REI physicians find their calling. Practice anywhere with Prelude. The Prelude Network is the fastest growing network of fertility clinics in North America.

With more than 90 plus locations, we're ready to support you and your individual career aspirations wherever they lead. To learn more, please visit rei.preludefertility.com. That's rei.preludefertility.com.

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser.

[00:01:22] Griffin Jones: You're welcome, people who are trying to recruit fertility doctors. I got a little bit ahead of the curve for you. I went out and found a sharp, engaged, first year REI fellow. And I asked her about how she's trying to influence her fellowship to design her career. Dr. Morgan Wilhoite might be a focus group of one, but pay attention to what she's paying attention to.

And if you're an REI fellow thinking about what kind of career you want after fellowship, or you're an OBGYN resident who's interested in going into the field of REI, you should pay attention too. Because we uncover advice to make sure that you're getting a proper cross section of people to talk to.

That it isn't just the kindergartners looking up to the fourth graders. To paraphrase Dr. Wilhoyt, we talk about particular resources that you should be consuming to get smart about how you're going to build your REI career. We talk about the particular areas of interest. Dr. Will Hoyt is interested in learning more about and fellowship, which I think is of value to you.

So that you get an idea of the trends of what it is that these young REIs want to work on. And we also talk about why Privedemic might become the default model for young REIs career preferences. Based on Dr. Wilhite's experiences, I give some advice to those that are recruiting young fertility docs, how to get ahead of the curve and not just being a dead dash to the finish when it comes to contract time.

I hope you enjoy this fun, lively conversation with Dr. Morgan Wilhite. Dr. Will Hoyt Morgan, welcome to the Inside Reproductive Health podcast. 

[00:02:49] Dr. Morgan Wilhoite: Thanks Griffin. I'm so excited to be here. 

[00:02:52] Griffin Jones: It's been a while since I've had a first year fellow on the program before. And I've, I've had many different fellows at different points.

Probably most of them have been second or. or third year and sometimes the reaction is like, well, why are you having fellows on? What do they know? Like, what do they know yet? There's a reason why I do it. A couple of different reasons. I think it's always useful just to constantly stay abreast of what it is that people are interested in, what they're up to.

And most of my audience is recruiting. REIs, and there are, they're either recruiting REIs or they're younger REIs that are thinking about the next phase in their career. And, and so maybe you can't advise those folks, but, or maybe you can, maybe there's, maybe there might be a nugget that, that helps them, but it also helps the folks that are thinking about the docs that they want to recruit, that they want to have as part of their team, not just for next year, but staying on the pulse of what the upcoming class of fertility physicians is interested in, I think is important.

And so I'm interested in now that you are, we're recording this in January of 24 where, which makes you halfway through your first year of REI fellowship. What did you set out to accomplish in your fellowship? In a, in a, I'm obviously studying the subspecialty, but like, what did you want to use it to frame your career?

[00:04:18] Dr. Morgan Wilhoite: It's funny that we started out, started out here because when I was preparing for REI interviews, I actually came across My file of all of my video recordings, where I was kind of talking to myself, interviewing myself about how I was going to answer certain questions. And I started rewatching them just out of curiosity while I was preparing for this.

And I realized, you know, I'm, I'm halfway through first year and I'm still relatively bright eyed and bushy tailed when it comes to being an REI fellow. But I was even more so when I was preparing for these interviews, I found myself just All over the place. I was wanting to do an MBA while online while I was pursuing fellowship and wanting to do, you know, the, the reproductive surgery scholars track and wanting to do some sort of a track where I did genetics incorporated into it.

And I, as you can see, I was kind of like all over the place. I wanted to do everything. 

[00:05:20] Griffin Jones: Um, luckily this is when, this is like, as you're applying for fellowships, this is like third year of residency, Yeah. Okay. 

[00:05:27] Dr. Morgan Wilhoite: Yes, exactly. I found myself just, you know, wanting to do everything REI. So it was funny to watch that back now since I'm a year and a half, two years out from that.

But when I now think about what I want to get out of fellowship, I'm really not only wanting to be a well trained REI and with that lately comes with the bread and butter IBF, right? That's what most RAIs are doing, but I am at a program where it's very academic and we are still seeing a lot of Bread and butter endocrine.

So we're doing a lot of hypo hypo. We're doing thyroid disorder. We're doing a lot of PCOS patients. So a good majority of our patients that we see are not actively trying to get pregnant. So I think that I am in a unique situation at this program where we're not just doing a million IVF cycles a year.

We are very busy with IVF, but we're also seeing general GYN and endocrinology. So I think getting out of fellowship, I want to be a well trained patient. reproductive endocrinologist. So I want the full scope of endocrinology and the infertility side of things. Also, I want to, you know, as, as much as I wish I could say, I want to be a full time researcher.

And I listened to your podcast episode with Dr. Devine about private MX. I do want to still incorporate research into my practice in some way. working with residents or fellows, probably more in the private and mixed setting, but you know, it's ever changing and I am still a first year. So I guess to answer your question, there are a lot of different avenues that I want to take to get really just the full scope of REI out of my fellowship.

[00:07:15] Griffin Jones: When did you start to pair back these really broad interests that you had? Like, like, how much do I want to to delve into genetics? Do I want to get an online MBA? When did you start to pair that back? 

[00:07:31] Dr. Morgan Wilhoite: Great question. When I realized that doing all of those things was not not possible. I, I always joke, I need like 10 more hours in every single day.

And you really do realize once you start fellowship that you're not really a master of none, you're a master of one, and you are super specialized in this field, which is one of the things that I love about it. So I'm realizing now the further I get into fellowship that I, I really want to find my and figure out what it is that I'm going to be.

doing on a day to day basis. And unfortunately that can't be everything. Um, that's just not realistic for, for any person to do all of those things.

[00:08:14] Griffin Jones: But when did that happen? Is this like, like after you started fellowship, you're like, Oh, maybe I won't get my MBA right now. 

[00:08:23] Dr. Morgan Wilhoite: Once I realized how busy I was in fellowship, which was surprising, I guess I thought that I would be less busy than residency, but I think I find myself working harder.

More cerebrally than I did in residency probably once I started you might be it's well 

[00:08:41] Griffin Jones: You made so you made an important caveat with cerebrally in that you're not doing the same number of hours Presumably as residency, but you're you might be the first person that I've heard say that I'm working more in fellowship than I did and in residency talk more about that 

[00:08:58] Dr. Morgan Wilhoite: Yeah, so in residency, there's a lot of doing.

There's a lot of checking on laboring patients and actively managing patients that are in the hospital. But in fellowship, there is a lot more thinking that's involved than it was in OBGYN residency. In residency, you kind of react to situations that come at you, whether that's through triage or patient support.

Changing their status on labor and delivery or in the med surg after surgeries, but in REI, it's a lot more planning ahead talking to patients about their future cycles or previous cycles, talking them about their embryos that are currently frozen, working through the things that They feel important for future family building and less of reacting.

So it's, it's more thinking, it's more preparing ahead of time. 

[00:09:56] Griffin Jones: So the fact that you started to, to realize, okay, maybe some of these other things will have to come later. Right now, my focus is going to be on the full scope of endocrinology and fertility. That suggests to me that that was not revealed to you during the, Interview process in the application process.

Why am I inferring correctly? And if I am, why is that the case? 

[00:10:22] Dr. Morgan Wilhoite: I think that when you are interviewing for any kind of a job, you start just thinking of all the possibilities of things that you can do. And I wouldn't say I was misled at all, but I was definitely. You know, just starry eyed thinking all of what the future has to hold and offer.

And it does have those things. You just really have to narrow it down and find a niche because being the person, the go to person on genetics, being the go to person on reproductive surgery, the go to on all things IVF, on endocrinology, on the, the, the. The business side of medicine, it's impossible to do all of those things, but very aspirational of Morgan two years ago when she thought she was going to be able to do all these things in one career.

But it's been kind of fun to see the things that I, that I thought that I could do one day and now kind of see the things that I want to do one day. 

[00:11:25] Griffin Jones: I'm going to put you on the spot with a question that I'm going to start asking everybody when we start talking about this topic, because I wonder if it's time, but what you're talking about really is the, this tendon, the trend that all fields of medicine and most sectors of the economy are moving to where the specialty becomes subspecialty, which becomes subdivided specialty and ad infinitum, right?

And, and so I wonder when We live in that type of world, should we still be having, should we still be sending 18 to 22 year olds to undergrad as a prerequisite for medical school? What do you think about that? I know I didn't prepare you for that. We didn't talk about that at all, but I'm just, I'm curious in, in what you think.

[00:12:16] Dr. Morgan Wilhoite: Love that question. I think about this all the time, actually, because in medical school, let me even go further back. In high school, it's, really hard as an 18 year old to say, you know, I want to be a doctor in general, let alone like what kind of doctor you want to be. Right. So I do think there is a period of growth that going to college and getting a bachelor's degree has, there's perks to that, right?

You, you grow a lot in college, you realize what you want to do. You kind of, live the, the fun part of your life that you never really get back that, that freedom of just exploring. So I think there is a place for it for sure, but there are a lot of years between high school and fellowship where I feel like things could be narrowed a bit.

One of those is I will die on this hill, but fourth year of medical school. Everyone knows that fourth year of medical school, you're kind of just hanging out. You're doing, you know, what you want to be doing. You're ending your year on rotations where you can, for lack of a better word, chill, because you've already taken step one.

You've already applied to residency. You probably already matched into residency. So I do think fourth year of medical school is a little bit overkill. It's kind of a very expensive vacation, so to speak, at least the second half of it. And then you go to residency, and this is another probably hot take on my end, but for OBGYN residency, I spent, you know, four years delivering babies, doing hysterectomies, doing the bread and butter OBGYN stuff.

And Didn't do, you know, any REI besides my couple, my one required rotation and then the additional things that I sought out because I wanted to pursue REI as a field. So I think that OBGYN, Eventually, I know there's been discussions of it so far, but becoming more of tracks into either the GIND track or the OB track, because while I think it's important that I know how, knew how at one point, to deliver a baby, am I ever going to be delivering babies as an REI?

No. And I spent four years. you know, perfecting that skill and doing thousands of deliveries. So they're a long answer to your question that I really, really liked was there's a lot of where places where you can kind of dial back on how much training you need to do this career. Yeah. 

[00:14:48] Griffin Jones: And I'm, I'm, the reason I asked the question, even though it's kind of a bit of a digression is I think it plays into how you're deciding what you want to do next with your career.

And at this point in your fellowship, you decided, okay, I've had to be broader in these different, I had to be more broad in residency, delivering all these babies. I had to have all these different rotations for the. your medical school when I already knew what I was going to specialize in, et cetera, that there is a spectrum of where we need to build a rudimentary foundation for different areas of medicine, but then we might be staying in that rudimentary phase.

for too long and not moving and wasting time where we could be specializing, especially when we need to further sub specialize and then further subdivide sub specialties as the field advances and gets more complex. 

[00:15:52] Dr. Morgan Wilhoite: Yeah, exactly. I mean, I'm full disclosure. I'm 32 and I'm very early on in fellowship. So I'll be 34 when I graduate and I will be looking for my very first job at 34.

And then there will be times in my career where I want to maybe do something a little bit different and further subdivide as you described it. And I could be in my mid forties or even 50 when that happens. And you really spend so much of your life leading up to this career that you've worked your whole life for.

And maybe by that time, your career that you've worked so hard for that you found your niche might only be 10 years after that, if that. 

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[00:18:46] Griffin Jones: Do you think with regard to finding that first job, do you think about it in those terms with your fellowship that I am trying to craft what I want to get out of that first job?

It's going to be the first time where I'm not. Uh, uh, applying to, to residency and getting, getting matched somewhere and fellowship match somewhere. I get to actually have some agency here. Do you think about how you're setting up your, your first job or do you look at, Your fellowship more generally and saying, well, this is what I want to study.

This is the knowledge I want to get. And then the job will come later.

[00:19:25] Dr. Morgan Wilhoite: I think both. I like the word that you said agency there, because this is a weird feeling. I don't know if I would describe it as weird, more just. I've never been in this position before where you're not trying so hard to prove yourself to get to the next step.

You know, all through high school, you're trying to get into a good college. Through college, if you know you want to go to medical school, you're trying to do everything to put you, yourself in a good position to get into medical school. Through medical school, you're putting yourself in that position to match into a good residency, and then through residency, same thing, to get into fellowship.

So there's all these, I like to call it, leading a life of contingency. It's like, I will get to the next step and be happy when I'm an REI fellow. And now I'm kind of at that stage where it's like, okay, I've, I've gotten into all of these things that I've strived to, to get into the place that I am now.

And now I get to really learn and craft my future the way I see it and the way I want to do it. And it's, An odd feeling because I've never gotten to do that before. I've always been trying to do the things to make me look perfect on paper for the job that I eventually want. And now I definitely have to rearrange my mindset to think, Okay, what, what can I do now to put myself into the best position to be the doctor that I want to be, to work at the practice that I want to work at?

Because now it's going to get to be my choice where I want to go and what I want my niche to be.

[00:20:58] Griffin Jones: To what extent is the first year are you able to shape your education to prepare of how you want to To practice in the future. 

[00:21:07] Dr. Morgan Wilhoite: Yeah, so I think I'm I'm lucky at my program because our my attendings It's kind of a close knit program.

We have Three will now four full time faculty and they work really closely with you So you can get out of fellowship what you feel like you need to get out of it to do what you want to do Of course, I'm at an academic program and I wish more people wanted to go into academics and I do and I love it But there are other things of course that I'm interested in and I feel well supported to do that For instance, my program is set up where I?

The first six months, you're kind of learning the ropes from the, what we call the IVF fellow. So you're learning kind of how cycles go. You're doing more of the low tech stuff, ovulation, induction, IUIs, and then you're also rotating through outside, um, services. So for instance, I rotated my first six months through adult endocrine Through pediatric endocrine where I did a lot of Turner syndrome clinics and transgender medicine I did DSD clinic and We do some genetics in there, too And then I was actually told by my program that if I found something else that I was interested in learning more about I if I could, you know make that connection and set that up for myself and it would be helpful for my future career, then I was encouraged to do that.

So I spent a considerable amount of time with peds endocrine because I was very passionate about fertility preservation and those populations oncofertility and then pediatric like Turner syndrome and Coleman's and the transgender clinics. So there were things that I was given a lot of autonomy on being able to explore further.

And I feel very lucky to have had that opportunity in my program. And then once January of your first year hits, you are the IVF fellow for 12 months. So it's you in the, in the clinic every day, doing the retrievals, doing the transfers, and it's less, more structured, less, You get to choose what you do, but to answer your question, there is a little bit in there your first year to get to explore and kind of tweak how you want your career to look and explore that.

But then yes, once you become IVF fellow, it's much more structured, which I think is a good, a good mix. 

[00:23:30] Griffin Jones: Is that to say that in your career, you want to be, you want to either be researching more and more of the latest in endocrine or, or that you want to be focused more on, on endocrine patients as opposed to doing IVF?

[00:23:49] Dr. Morgan Wilhoite: Not necessarily, but I want to have a lot of that background knowledge to be able to do some of those fertility preservation cycles for patients that have like Turner's mosaic or Oncofertility and I think because I was able to explore that so much in my first six months I now have an idea of what that would look like in a future practice taking a those patients and especially the pediatric patient population.

There are some centers that don't do a lot with fertility preservation for the pediatric population for various reasons. So I think being able to explore those different things in endocrine and the different genetic things are, were definitely aiding to the ability to kind of Figure out what I want to do later on 

[00:24:38] Griffin Jones: right now is privademic at the top of your list.

If you're thinking of practices in general categories, academic or independently owned or part of a network or private Demick is, is that at the top of your list? 

[00:24:51] Dr. Morgan Wilhoite: I think so. And again, this is, you know, I'm still in that. starry eyed first year fellow thing where I'm, I could see myself doing a lot of different things, but definitely being able to, um, to mentor and teach on a medical student level, resident fellow level.

I want to be involved in education. Um, and in doing so, I wouldn't like to be involved in those, um, different levels of research, um, helping medical students, um, Residents and fellows get research projects off the ground, helping them kind of understand how to read research. All of the things that my mentors have done for me getting to this point.

So, Privademic seems like kind of the way of the future. And I, I love that word. I love that you just did this podcast with Dr. Devine about this, because I don't want REI to lose that. in the future. I don't want it to just be everybody doing IVF cycles and nothing else. I think that there is definitely a, an advantage to keeping the research going, keeping providers in groups that want to be research mentors and just mentors in general of 

[00:26:01] Griffin Jones: When you say that PrivateMX seems like the way of the future, is that also to say that it is the future default of REI Fellows preferences?

Like, because I'm, I'm, look, when I talk to Fellows, some of them want to do research for full time, but not too many, like real anecdotally, I'm thinking one out of five, something like that. Very few want to start their own private practice, but also very few that I could think of would say that they don't want to do any research.

And maybe that changes as they've been practicing for three or five years. And like, I'm, I'm. Good. Not doing the research. I want to do as many cases as possible and see as many patients as possible. And then the rest of the time with my family or something else, go going to get that MBA. But it seems to me like at least coming out of fellowship, very few people are saying that they don't want to do research and, and not very few, but.

Few people are saying that that's all that they wanna do. So do you think that Priem is, is is gonna be the default for that reason? 

[00:27:12] Dr. Morgan Wilhoite: I hate to call it a default because it just seems like this perfect mix of clinical and academic, which is exactly what it sounds like in the name. But for lack of a better word, I guess, yes, default, it does kind of seem like that's the way things are going because all of these companies that are now owning or partnering with academic centers, there are very few academic centers that are just purely academic anymore.

And I agree with you. I don't see many fellows graduating saying I want a full career in just research. And I think part of that may be, this is me speculating, but maybe because people don't want to lose that ability to communicate with patients and do more of that bedside doctoring. And I think that's a skill that is needed.

You just get better at, with time, communicating to patients in ways that they understand because REI is confusing. It's confusing to patients to talk them through an IVF cycle. So, I, I think that it's probably, yeah, the way of the, the future because it's a good way to hold on to both without having to, to give up one or the other.

But I would love to know how many fellows graduate saying they want to continue doing the IVF. Research and academics and how many 10 years later are still doing research and academics. I feel like that would be an interesting number. 

[00:28:29] Griffin Jones: Yeah, me too. I, because I suspect that it's different because people just say, yeah, I want to stay involved in the research.

But then when you get into the, the, the real life of work and family and career, and I wonder how much that changes, but default might not be the preferred word, but it. To your point, if it really is the perfect mix, then it's better that the default is the perfect mix as opposed to a much lousier alternative.

[00:28:58] Dr. Morgan Wilhoite: And again, it's easy for me to say because I don't have children. I'm not married, so it's easy for me to go home and read or work on research and that kind of thing. But, you know, in 10 years from now, if I have children and a family, my priorities may change. So you just never know what your future is going to look like until you're, you're in it.

[00:29:18] Griffin Jones: Are you thinking about jobs right now? Like, are you starting to talk to folks? Like what, what level of research are you doing right now? 

[00:29:28] Dr. Morgan Wilhoite: Yeah. So I'm very lucky that I have Meg two years ahead of me. You and I both know Megan Sacks. I'm going to give a shout out to her on this, but she has been instrumental and, you know, a mentor to me going through this whole process.

And she kind of, you know, plants little seeds of, Hey, this is a really good group. These people are hiring. And she knows, I know I'm, I'm a free agent. I'm not stuck to one place. And I, again, I don't have a family that I would have to uproot to a different part of the country. So I would say, yes, I'm starting to think about jobs for sure.

I haven't started interviewing or taken any steps toward looking at contracts, of course, but I, I think about it often. 

[00:30:11] Griffin Jones: Okay, so we're pre interview, pre contract, that sort of thing. Have you had soft conversations with potential employers? Yes. What have those been like? 

[00:30:21] Dr. Morgan Wilhoite: More like, we are going to be expanding in two years, which is a perfect time for when you're going to be graduating.

What are your thoughts about, you know, moving to this area? So, without divulging too much, yes, I have had some Conversations, but nothing has been, you know, let's sit down and look at a contract together at this point. 

[00:30:44] Griffin Jones: How much do they or you stay in touch in, in that situation where it's like, Hey, we're going to be here.

And maybe that's of interest of you. Is it something that it's like, Hey, call us back when you're, when you're, you know, halfway through second year, a little bit, maybe not. They, they probably don't want to wait that long. They probably would, would like to, to ink something sooner. But call us back when you think about this or are they, you know, maintaining a relationship with you, staying in touch?

Are you doing likewise? Or is it, is it more like we had a conversation and maybe I'll revisit that conversation later. 

[00:31:18] Dr. Morgan Wilhoite: Yeah, more like the latter, how to conversation, like reach out when you are, you know, ready to start seriously interviewing, keeping in touch, you know, at conferences and that kind of thing, of course, or if, you know, mutual friends cross, cross each other's paths, good way to reach out in that way as well, but more so of let me know when you're ready kind of conversations.

[00:31:43] Griffin Jones: Transcribed People doing the recruiting, listen up. You're missing the boat, man. People posting on LinkedIn, come to our event at PCRS. Come to this thing. Oh, yeah. We have an opening in Austin. You and everybody else has an opening. And so, I think that might be A little insight into where people that are recruiting young docs could have an advantage of if you are having these soft conversations with first years, with maybe even second years, maybe even people in fourth year residency that aren't sure if they're going to get, Where, what fellowship program they're going to get accepted into, but they think they want to go into REI, maybe add those folks to a CRM or, or some way of keeping track of them and actually nurture that relationship over time.

[00:32:34] Dr. Morgan Wilhoite: Yeah. And I don't want to speak for the whole group of first year fellows, but I would say I'm probably speaking for a vast majority of us is, you know, it kind of makes you feel like the bell of the ball when people are reaching out to you and just. You know, planting the seed of, Hey, when you start looking, we might be hiring in the next two years, or this is what our practice looks like, or just reaching out.

I think that if this reaches any of the recruiting docs, first year fellows love that they, they like to feel like finally we are the ones that are being sought after and not having to reach out to, to secure a spot for ourselves. So. Definitely reach out. That is my advice. If that's not a weird dynamic of me offering advice, I don't think that it is.

[00:33:19] Griffin Jones: I'm I'm offering that advice to the networks, to the clinics, to those that are recruiting younger docs. And I understand that recruitment is like sales were very often. Too busy to do the longer term work because you have to fill a position now. And so you're, you're trying to focus on that, which is immediately going to be available where you're going to be able to see the fruits of your labor sooner.

But I think that there is a real advantage in starting those relationships early. Cause if I'm a recruiter, Morgan, and I know what you like, and I know what you're up to, and I want, and I know. Where are you going to go? I want to just check in with you every now and again, drop you a text when we're opening that new office, or if our research institute is doing some study, I want to, I want to let you know that, oh, that's, that's in one of the areas that, Morgan's really interested in.

So I think that's just a little insight that I hadn't really uncovered under the, on the show, because I had always just sort of assumed that, well, it just keeps getting earlier and earlier the recruitment phase and it does, but maybe not in earnest, right? 

[00:34:29] Dr. Morgan Wilhoite: Yeah. And I think there's probably a little bit of hesitation from a recruiter standpoint of, I don't want to come off sales and pushy, but from a, a Perspective employer employees standpoint.

I do think that reaching out earlier kind of puts It puts that in your mind of, oh, this person reached out when I was really early on and that's nice to be thought of early on, whether or not it's because they just really need people or because they feel like my personality would, you know, click well with their group.

Either way, it, it is definitely a good feeling when people are reaching out and letting you know that the job's coming available. 

[00:35:11] Griffin Jones: What sources of information are you going to for what jobs might be a good fit or just, or for what you're considering for your career? Like, are you going to docs that are associate REIs someplace?

Are you going to the networks themselves and talking to the founders? Are you just asking the folks that are on the board of SREI that do the, Retreat at Park City. Are you like trying to read business info? Are you just in a WhatsApp or iPhone message group with all of the other first years? And it's the blind leading the blind.

And uh, if you'll pardon the expression, or are you talking to the third years who are like the kids 10 feet ahead of you in the haunted house and asking them what's coming next? Where are you getting, where are you going to, for, to make sense of all this? 

[00:36:03] Dr. Morgan Wilhoite: I love your analogy, Scriven. That's great. So it's almost like when you are in kindergarten and you look at the fourth graders and you're, like, looking at what they're wearing and what they're doing and it's like, I want to be like them one day.

That's kind of how the first year fellows, I feel like, are treating this problem. process. We're looking at the third years who are, again, I'll use my analogy, the bells of the ball. They're getting recruited, they're getting job offers, they're signing contracts. It's super exciting. You're living kind of vicariously through them.

So definitely through the third years, again, Megan Sachs, who has is my wonderful third year fellow here, secured a job recently, signed a contract and will be moving to Chicago. And she has been a great source of information of You know, which, which contracts look good when, because she talks to the other fellows who've also signed contracts that, and then again, the first year fellow, what's that kind of the blind leading the blind.

We haven't really delved into discussing contracts or anything yet, but more living vicariously through the third years of the things that they're doing. I always say this in medicine and it's a shame that it's never come to fruition, but we really need to be taught. More of the business of medicine going through medical school, residency, and now fellowship, you, you don't have that big piece of medicine and that's a lot of what REI is, is business.

So I think that it's I wish you said, read a book. I have read books and it's hard to make sense of a lot of it. You almost have to like have a confidant of someone you can say, all right, this is a really dumb question, but just talk me through this business model or our views versus, you know, salaries, guarantees.

It's, it's a lot of lingo that you don't start hearing until you really start looking into jobs or hearing people talk that are looking into jobs. 

[00:37:56] Griffin Jones: So in the absence of getting an online MBA, where do you go to, to get that sort of business education that you're not getting in med school or residency or fellowship?

[00:38:06] Dr. Morgan Wilhoite: I'll let you know when I find a good source. I mostly, you know, things that I've talked to or people that I've talked to that have been through the process. I do have a few friends that have gotten their MBAs that are in medicine and they've kind of shed some light on some of the things that just sort of are a little bit more nuanced than what I'm privy to being purely clinical this whole time.

So I, I would love to one day get an MBA and be able to understand it more, but I, I think that I'll keep you posted if I find a good student. source, or if you know of a great source, 

[00:38:42] Griffin Jones: well, hopefully we're doing a little bit of that here on, on this show, we don't have anything like online training modules, but I would say if I was at least geek out on every one of these episodes, you know, you got to drive somewhere.

You got a little listen to something when you're at the gym. So might as well put this on, especially when you're thinking about what comes next, but who has done a better job of actually putting it into modules is my, my friend at work. Duardo Herriton, who has has made the fertility explain series. And, and then in addition to those things, I think through there, you'll, you'll find more people to talk to.

You'll also find different resources that we drop along the way of like, oh, here's the best business book I've read, read, written. Or read in the last three years, I should say, and this is why. And so I think that that's a, maybe a little piece of advice for, for the younger docs. And then something that you said made me also think if, if I'm qualified to give advice, which I'm not, but it doesn't stop me from doing it.

is get a bit of a cross section of people that you're talking to. Like if first year fellows are only talking to third year fellows, it's like, they don't have a job yet. Like definitely, which is not to discount the knowledge that they have because they're in the system and they're the ones who know you know, what's most current and they're talking to all their peers and they talk to eat different potential employers.

And so they know what's current and, and, and they do have really valuable knowledge to share with you. But then you might talk to somebody who's an associate doc that worked at a practice for three years. And then you might talk to someone who is a newer partner. They've been working at a practice from five to seven years and became.

partner a couple of years ago and what that's been like. And, and then talk to some folks that are there further on in their career as well, and use the amalgamation of all of that to inform your decision, because I could definitely just see, I could just visualize all the first year fellows. You know, WhatsApp group together, pinging each other back and forth with that sort of thing, which to me suggests sometimes that they're doing that because that's the easiest person for them to talk to.

And they're either shy or, you know, they're, they're bashful about not knowing something. Do you find that to be the case with yourself sometimes? Do you, how often do you just reach out to somebody out of the blue? 

[00:41:08] Dr. Morgan Wilhoite: Right, exactly. So it's, I don't know if I would call it shy more. Like we, it. In general, physicians don't like to have conversations and not be able to bring anything to the table, right?

Like, we are used to being kind of the expert on things. So, I think being, you know, most of us in our 30s, reaching out to someone saying, Hey, can you explain this to me? It would be like me reaching out to my financial advisor and asking him, like, about my taxes. Like there's just things that I know so little about that I don't know where to start or what questions to ask.

So yes, I, I think that getting more information from the right sources would be ideal, but it is, it's hard when you don't really know where to start or who to go to. 

[00:41:59] Griffin Jones: So you don't do it terribly often then, like, would you, if you heard a guest on this show, for example, that you thought was really interesting, would you reach out to that person on LinkedIn?

[00:42:09] Dr. Morgan Wilhoite: Oh, maybe not on LinkedIn because I don't know my LinkedIn password, um, but I would, yes, if you provided information, I would feel comfortable reaching out, um, especially if they had put themselves out there, like, to say, you know, I'm, I'm open to communication with people that want to know more about this a hundred percent.

Sometimes it's just information overload. When you go to Google what books are best for the business of medicine, it's, you get a huge list of things and it's hard to kind of pick out one What information is the best, which I think, like you said, it's easiest to go to people that can give you little bits of information in a digestible way, like friends of friends, or for instance, I recently graduated OB GYN and a lot of my friends that are now in private or hospital owned generalist groups.

I've gotten a lot of information about contracts in business from them because some of them are on a partnership track or can explain a little bit more about their guarantees or RVUs, but I don't know how applicable that is to my field because REI is much different in terms of a business setup than generalist OBGYN.

[00:43:16] Griffin Jones: When it comes to potential employers in the future, are you of the ilk that, well, I'll just talk to anybody, or is it a bit, is there a bit of apprehension because it's like, well, if I talk to this person, then, you know, then I feel like I either owe them something or they're, I I'm worried about wasting their time.

And, and then I feel like I've got to give them more of my time in order for it not to be a waste. And I would rather just. put all of that off for a second until I decide a little bit more who I want to, to talk to. Like, are you, are you of the shotgun approach or is it more like, I'm a bit apprehensive because I don't want to start getting recruited just yet.

[00:44:03] Dr. Morgan Wilhoite: No, I would say I'm, I'm a little bit of both. I am very open to getting recruited cause I want to know what's out there. At this point, I kind of only know Ohio cause that's where I've been for so long. Um, I think just being really upfront and honest, like. I'm first, I'm halfway through my first year. I still have a long time to go.

I'm kind of just looking and seeing what's out there and being very transparent in those conversations. If someone were to reach out to me, you know, I'm, I'm still looking to see what's out there rather than not wanting to waste someone's time. Cause I don't, I think that getting more information is a waste of anyone's time, especially if you're not setting up like a hour long meeting with them and taking up their time.

If you have no interest in going there, if I was recruited to Alaska right now, I think that that would, I would probably be transparent in that I might not be moving to Alaska, but in terms of other places or business models, I'm open to hearing whatever's out there and just being very transparent, that I am still just very early and.

Continuing to keep my options open and look around. 

[00:45:08] Griffin Jones: Do you have a, an idea of preferences of where you'd like to end up geographically? 

[00:45:13] Dr. Morgan Wilhoite: I go through this every day when I live in Ohio and it's five degrees. Like, oh gosh, I'd love to move to somewhere warmer. But then, you know, I'm from the Midwest. So to answer your question, no, I have My family, my parents are in Ohio, but otherwise I could see myself going a lot of different places.

Just depending on the weather in Ohio that day, you can ask me. 

[00:45:36] Griffin Jones: So Alaska is off the table, but are there other, are there other places where you think no, either that's too rural or it's too, like that would be too far or that's, that's too large of a city. Like, are there, so if you're still paring down where you want to be, are.

Have you pared down some of where you don't want to be? 

[00:45:58] Dr. Morgan Wilhoite: A little bit, yeah. I think I would be most, I guess the area where I compare it on the most is I want to be in an area where I can easily refer patients to, to multiple specialties. So if someone needs a, a referral to psych, not having to be in an area where they have to drive two hours to get there.

to see a psychiatrist in person or if someone needs a referral to GYN oncology, having like an internal referral system, maybe not in the same hospital, but at least near. I think that that is important to me to have a community of people that I can not only reach out to with questions that are more geared toward their specific needs.

specialty, but also send patients to if I'm concerned about a malignancy or if there's a cardiology concern. For instance, I mentioned Turner's patients. There are a lot of cardiac anomalies that can go along with having Turner syndrome. So if those patients need MFM referral to discuss pregnancy complications or if those patients need cardiac clearance to be able to carry a pregnancy, those are the kind of.

Places that I'm interested in practicing where there is a, a community of other physicians that I feel comfortable going back and forth with. 

[00:47:10] Griffin Jones: I'll let you conclude on, on this topic, whether it's about how you're structuring your fellowship to get what you want out of your career or, or what you're looking at to be able to do once you get that dream job and, and be able to practice in that way.

How would you like to conclude? 

[00:47:29] Dr. Morgan Wilhoite: Well, I think we've covered a lot, a lot of basis here. I think in conclusion, I would say I'm interested in practicing at a group in a group that is willing to let me kind of see the patients that I'm interested in seeing, have autonomy, get involved in the business side of the practice.

And then also just having great partners to work with. I've realized through many. Years of medical training that the people that you work with can really make or break your, your daily mood and your general outlook on medicine. So having good partners, support, mentorship, all of those things are important to me.

So that's, I think that that probably can echo what a lot of first year fellows would say is we want to be able to go to someone that has more experience to ask for help and also be happy where we're working. 

[00:48:26] Griffin Jones: Well, you've put yourself out there, so if any of these folks are smart, they will use this as an opportunity to reach out to you, and they'll take our advice, and they'll stay in touch with you and build that relationship over time based on what you've shared you're interested in, and I appreciate you doing that on this podcast.

Dr. Morgan Wilhoite, thank you very much for coming on the Inside Reproductive Health podcast. 

[00:48:49] Dr. Morgan Wilhoite: Thanks, Griffin. It's a pleasure. 

[00:48:52] Sponsor: This episode was brought to you by Prelude Fertility, where top REI physicians find their calling. Practice anywhere with Prelude. The Prelude Network is the fastest growing network of fertility clinics in North America.

With more than 90 plus locations, we're ready to support you and your individual career aspirations wherever they lead. To learn more, please visit rei.preludefertility.com.

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health nor of the advertiser. The advertiser does not have editorial control over the content of this episode and the guest's appearance is not an endorsement of the advertiser. Thank you for listening to Inside Reproductive health.

215 Minimizing IVF Patient Dropout with Empathic Communication with Dr. Alice Domar, PhD

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


IVF patients are dropping out and it isn’t just about the money.

Dr. Alice Domar, Chief Compassion Officer at Inception, discusses empathic communication and its role in minimizing patient stress and physician burnout.

With Dr. Domar we dive into:

  • Her definition of Patient Centered Care

  • How she measures patient stress (comparing against retention rates)

  • An example of a study she ran (the 67% difference in patient dropout)

  • Her format for teaching empathic communication

Common trigger points for patients (And their impacts on your reputation as a physician)


Dr. Alice Domar PhD
Chief Compassion Officer, Inception Fertility, Director, Inception Research Institute


Inception LLC
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Prelude Fertility
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Transcript

[00:00:00] Dr. Alice Domar: The clinics should worry because if patients drop out of treatment, they're not going to get the income. Pharma's not going to get the income. And I worry because the patient's probably not going to get pregnant. by the time she gets to IVF, and she drops that IVF, the chances of her conceiving spontaneously through sex are pretty low.

And so it breaks my heart to think that people get to treatment, may even have insurance cover for treatment. And find it so stressful they drop out. And that's, where we are doing something wrong. People should not be dropping out of treatment because they're too stressed to continue. 

[00:00:37] Sponsor: This episode was brought to you by Prelude Fertility, where top REI physicians find their calling.

Practice anywhere with Prelude. The Prelude Network is the fastest growing network of fertility clinics in North America. With more than 90 plus locations, we're ready to support you and your individual career aspirations, wherever they lead. To learn more, please visit rei.preludefertility.com. That's rei.preludefertility.com.

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode and the guest's appearance is not an endorsement of the advertiser.

[00:01:32] Griffin Jones: IVF patients are dropping out and it ain't just because of money. You can't help people get pregnant. You can't help people have a family. You can't scale fertility treatment. If people are dropping out for reasons within our control. If you own or operate fertility clinics, what does that mean for your business?

And if you're a fertility physician, how does it all come back to the way that you communicate? What does it even mean to train fertility physicians in empathic communication? My guest today has studied all of this more than anyone as far as I know. She's Dr. Alice Domar. Now she's the Chief Compassion Officer at Inception.

And she's working on reducing patient dropout by reducing patient stress. And she's working on reducing provider and staff burnout by reducing provider and staff stress. Allie talks about the studies that she's done and other studies that have been done on psychological interventions and patient centered care.

I make her define patient centered care. We talk about how she's measuring patient stress now and how she plans to compare those to retention and dropout rates. We talk about an intervention that she did in the past of a sample of 166 women where half were given this intervention, half were not. It's one variable and there was a 67 percent difference in patient dropout.

I ask her to describe the format and how she's teaching fertility physicians empathic communication. What does that training look like? And I push Allie a bit on the tension between alleviating patient burnout versus alleviating provider and staff burnout. I think there's a natural tension there and anybody who says otherwise is lying.

I'm not saying that it can't be managed. And I think Allie has a way of managing that. Tell me what you think about her suggestion and tell me what you think about physician communication as it relates to IVF patient dropout. Join my conversation with Dr. Allie Domar. Dr. Domar, Allie, welcome back to the Inside Reproductive Health podcast.

Dr. Alice Domar: So good to see you. 

I don't remember if this is your second or third time, but you were on one of the earlier episodes. You're someone that I've gotten to speak with at events before. I love seeing you speak at events. I love interviewing you. You're a chief compassion officer right now. And I am. One of the things about me is I don't like a lot of C titles.

I think C titles are way overused, but If there is a chief compassion officer and someone is qualified to be one, that is you. And so I want to talk a little bit about what it is that you do in this role at a network level that is a way of thinking about how we introduce things that are necessary for patient care and for patient retention.

But having somebody oversee at least some of the critical elements of that, Cross the scale of the organization. So what is it that you do at a, network level? 

[00:04:19] Dr. Alice Domar: Nothing. I'm just, I just goof off now. I, we really, when I went down to Houston to meet with TJ Farnsworth and the rest of the executive team, no one really remembers who came up with the job title.

I think it was TJ. He thinks it was me anyway, doesn't matter. But it really is a perfect title because, I've spent my whole career working to decrease the stress level of infertility patients and people who work in the infertility clinics in the sector. And so I've since added another title as I'm director of research for Inception, which probably adds another 50 percent of my life.

But I think to summarize it. I spend a lot of time trying to create and provide programs to our patients on how to decrease stress. So for example, tonight at nine o'clock Eastern time, I'm doing a webinar on, for family and friends of people who are going through infertility on basically do's and don'ts, like how can I best support someone I love with infertility?

And so I do monthly webinars. for patients. This is my first one for non patients, but I do monthly webinars for patients. I, if there's a patient in crisis, I talk to the patient. I write blogs on how to reduce stress. And I basically am just there for all of our clinics if there are any issues with the patient.

And as I said, I, talk to patients directly. And then another hat I wear is I try to provide programs to employees. Like in the last year, we've gotten a free subscription to the com app for all employees. I do this ask Allie column in their weekly newsletter. I'm starting a podcast this month for employees and how to reduce stress.

And if an employee is in crisis, either HR or their manager or the employee contacts me and I talk them through it. 

[00:06:16] Griffin Jones: So you've got these two different sets of programs, one for decreasing stress for patients and the programs that fall within that line, and then the other line being for decreasing stress for employees.

Are there indicators that you're ultimately responsible for or looking at that, that help you to decide that govern what those programs become and how you measure their success? 

[00:06:42] Dr. Alice Domar: Not yet, but that's in fact, I think one of the reasons why I'm running the Inception Research Institute because we're actually doing studies on the efficacy of different psychological interventions.

Although right now our research is mostly trying to understand. So for example, I have a study funded by MD Serrano where You know, for 10 or 12 years, researchers in Europe have been talking about patient centered care. And research actually shows that patients prioritize patient centered care over pregnancy rates.

women who are going for treatment right now really want to be cared for by compassionate, empathic physicians, nurses, and the team. And so everyone is always saying, oh, this is what patients want. But no one's ever really asked patients what they want. So we're doing a survey right now where we mailed a questionnaire to our patients to say, what are your priorities?

is it communication? Is it how to handle finance? everything. And so we will have the data hopefully released soon because I'm presenting it at PCRS. So we'll have the data soon. We're also on a LARC, gave the same survey to our physicians and asked them, what do you think your patients want?

And we're going to compare what the physicians think patients want versus what. patients say they want. And so once we know what the patient's priorities are, then we can make changes in the clinics to respect and reflect on what patients say they need, as opposed to you or I saying, Oh, I think this is a good idea.

This is what patients need. We're actually asking the patients what they need. 

[00:08:21] Griffin Jones: How do you juxtapose what patients say they want to need versus what their behavior suggests they want and need? And I'll give you an example that I'm thinking of. I remember, it was probably like 10 years ago or 8 years ago or so, Wash U Fertility did a survey of fertility patients.

And they might have done it in connection with Sirona. I don't remember who they did it in connection with. But they interviewed patients asking them what they liked and what they didn't. Want to see in social media. And what they said is we don't want to see pictures of babies. We don't want, we want tips on fertility, but then I could pull up all of our different clients, Facebook and Instagram analytics and say, it was almost like reverse alley.

It was like the pictures of babies did ridiculously well. And so you can say I don't want to see this, but then they're clicking on it. that's what they're, that's what they're paying attention to. That's what they're being driven for. And so I, I see. I've, seen this, with, employees, I've seen this all over the place.

It goes back to that Henry Ford quote of, if I asked my customers what they wanted, they would have told me they wanted a faster horse. Don't know if he actually said that or not, but, people can get the idea. how do you juxtapose like what people say they want versus, making sure that the, tail isn't wagging the dog.

[00:09:46] Dr. Alice Domar: first of all, I think a lot of the data that's been collected in the past was done in focus groups where you have, six or eight or 10 people meeting with somebody who asks them. And I don't tend to believe results from eight or 10 or 12 people. In fact, this morning I was asked to review a study that included 13 patients and they drew all these conclusions from 13 patients.

And I said, that's. That's insane. You can't draw conclusions from 13 people. And so we've already collected data, I think, from at least 500 patients. We're hoping to have at least a thousand. And when you have numbers like that, you can relatively safely assume you're actually getting real data. And then.

Before we actually implement these changes, we're going to do another study where we're going to take two of our comparable clinics, like maybe two of them in Florida or two of them in Texas, and take all the suggestions that patients said they wanted and make those changes at one of the clinics. And then compare patient satisfaction, patient dropout rates, things like that to see, yes, you're right.

People do say things that they want, but you also tend to get more. honest answers from these anonymous questionnaires versus talking to somebody, especially somebody who works at the clinic. 

[00:11:06] Griffin Jones: Yeah. I think that's a good way of looking at it too, is can you see from their answers how well do they line up to some of those numbers like dropout or conversion or retention?

Is there a way to do something like this, Sally, I remember there was a conversion rate Specialist that I follow in marketing, I think his name's Brian Massey, and I was at one of his workshops and we were going through this type of thing. And very often when people are trying to workshop a new campaign or a new website, they'll ask questions like, was this website clear?

Was this website appealing? Whereas he suggests. studies that show, show, did people buy it more or not? Or in the case of, if you're trying to get some kind of brand messaging over the line and it can't be tied to a particular conversion, he'll still suggest asking people what is it that this website does, or what is it that this company does after looking at the website homepage, as opposed to Asking people if the website was clear, is there any way to do that in your survey mechanism?

[00:12:18] Dr. Alice Domar: I think you're right. it's, tough to assume that people report exactly what they want. So for example, in all this research, because in Europe, they're way ahead of us in this patient centered care. But they did, I don't even know how they got the data, if it was focus groups or what, but they, said there are five things that patients want in terms of patient centered care.

And I don't remember what three of them were, but two of them were more information on the semen analysis and more information on the impact of a high BMI. I've been in this field for 36 years. I have never had a patient say, I want more information from the semen analysis. And most of my patients. don't want to know the impact of the BMI because they know that being heavy or too light, impacts their chances and they don't want to hear more about it because they already know it.

So I think we have to be very careful how we collect data. it's if you look at some of the old data from like before 2000 on the psychological impact of infertility, there were a number of studies that showed that women with infertility had the same level of anxiety and depression as did anybody else.

Yeah, but they were also. being asked to rate their anxiety or depression in their clinics, sometimes with their doctor present. And they would want their doctor to think that they were fine, that they could handle treatment just fine. Cause they didn't want the doctor to know how upset they were. Cause then the doctor would say, Oh, you're too upset to do treatment.

And so a groundbreaking study happened in 2004, where they actually had. a psychiatrist, interview, do a structured psychiatric interview before patients saw an infertility doctor for the very first time. And 40 percent of them met the criteria for anxiety, depression, or both. So sometimes these self report mental health assessments, let me rephrase that, many times these self report mental health assessments are not very accurate.

And if you go to countries like Scandinavia where People don't tend to talk about being anxious or depressed. You're going to get scores of zero from people who in fact are probably very distressed. 

[00:14:26] Griffin Jones: So you're working on getting some more of this data right now with the studies that you're doing.

In the absence of this data in the meantime, how do you decide which programs that you want to usher in and that you think will have the biggest impact? 

[00:14:43] Dr. Alice Domar: I look at the research. there's been, I don't know, a hundred randomized controlled trials on the efficacy of different psychological interventions.

obviously I started the MindBody program in 1987, so I'm a little biased towards MindBody, but in fact, there's been a group in Denmark who've done two huge meta analyses on the efficacy of psychological interventions with infertility patients on both psychological symptoms and pregnancy rates.

And both of their meta analyses have pointed to, mind body stress management interventions as being the most effective. and that's not me doing the research, that's them doing the research. It just makes me feel good because that's the intervention that I'm most familiar with. 

[00:15:28] Griffin Jones: tell us more about the programs.

What programs developed from that? 

[00:15:32] Dr. Alice Domar: So the MindBody program, it used to be an in person 10 session program. Obviously, now everything is remote. But we've also shown, I had a graduate student from UVM who took the in person MindBody program. And we've done a bunch of randomness control trials on it.

But she took the in person program and made it into an individualized online program. And this is before COVID, and this was her PhD thesis. And we found that women who did the MindBody program by themselves on their computers, not only had massive decreases in depression and anxiety compared to the control group, but their pregnancy rate was four times that of women who were on the waiting list control group.

I could talk for two days about The efficacy of these interventions. We know that our patients are distressed. We, know that a lot of them are anxious. A lot of them are depressed. Their partners are anxious and depressed. And, I was at a conference last year in Boston. I don't remember if you were at the same conference.

It was over Valentine's day. And it was on reproductive medicine, I think in women's health. And I actually got up at the end of the conference because they're all talking about all these technologies and all, AI and everything else that can be used in reproductive medicine. And I stood up at the end and I said, look, I'm the only mental health professional in this entire conference.

No one has mentioned. The emotional health of our patients. But if someone is really distressed, we know for a fact, they're not going to go see an infertility doctor. They're not going to start treatment. The more depressed a woman is before she starts IVF, the more likely she is to drop out after only one cycle.

all of us should be caring about our patient's mental health. I, as a psychologist, because I don't want these women to suffer psychologically. But the clinics should worry because if patients drop out of treatment, they're not gonna get the income, pharma's not gonna get the income, and I worry because the patient's probably not gonna get pregnant.

by the time she gets to IVF, and she drops that IVF, the chances of her conceiving spontaneously through sex are pretty low. And so it breaks my heart to think that people get to treatment, may even have insurance cover for treatment and find it so stressful, they drop out. And that's, where we are doing something wrong.

People should not be dropping out of treatment because they're too stressed to continue. 

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[00:20:17] Griffin Jones: I want to come into how this impacts dropout. I wonder if one of the reason why they didn't mention that at that tech or that innovation conference, perhaps two reasons.

What are people in that sphere obsessed with? One is measurables of certain metrics and they want very specific attribution. And we talked about some of that thing that you're working on. The other thing that they obsessed with is scalability. it's got a scale. And so are there. Technological solutions.

You mentioned that one of the things that you all are doing is getting subscriptions to the comm app for your employees. are there technological solutions that scale to reduce stress for patients? 

[00:20:55] Dr. Alice Domar: I haven't seen a whole lot of research yet. I know that Jackie Boyvan in Europe. is working on an app called Metaemo.

And the, at Esri a few years ago, she presented data that showed that women who use the Metaemo app were twice, who did IVF, were twice as likely to come back and do a second cycle than women who didn't use the app. We did a study, I, did it with Jackie. maybe six years ago, I don't remember how many years ago, where we recruited women, I think 166 women, who are about to do their first IVF cycle.

And we mailed half of them a stress management packet. So it was like cognitive behavioral skills. It was a relaxation CD. It was teaching them how to do mini relaxations. So we mailed them a half of them and then sat back for a year, didn't contact them, and then looked at retention rates. And the woman who got the packet, we don't know if they opened the packet, we don't know if they used the packet, the woman who got the packet in the mail reduced dropout rates by 67%.

Wow. And that packet cost 12. 

[00:22:00] Griffin Jones: And there was no other control? So we know that, 

[00:22:06] Dr. Alice Domar: no, we had a control group. We took 166 women. 

[00:22:09] Griffin Jones: but otherwise the groups were identical, like demographics, where they lived, and Absolutely identical. That 

[00:22:15] Dr. Alice Domar: was the only variable. Randomized controlled study. And then we just published a paper last year, and we tripped over this.

in my previous job, I was very interested in dropout rates. I'm in Massachusetts, six cycles mandated coverage. And we noticed that a lot of patients came in for a first visit and didn't come back. And I'm like why wouldn't they come back? They have insurance coverage. So we actually just sent them an email to say, Hey, we noticed that you saw an infertility doctor three months ago.

We noticed you haven't come back. We're just wondering why do you not like the doctor? Are you pregnant? are you taking some time off? what's going on? And we got a lot of answers, but. My research assistant noticed that a lot of the patients who got the email were coming back, like a lot of them said, Oh, I'll come back.

And then she went on maternity leave. So we didn't send the email out for four months. So we were able then to compare. When we sent the email out just asking, why didn't you come back versus when we didn't, massive increases in people coming back simply by getting an email saying, hey, we noticed you didn't come back.

So the conclusion I draw from those two studies, it takes very little to support patients to come back or to stay in treatment. And yet most clinics aren't doing anything. 

[00:23:41] Griffin Jones: There's a bunch of rabbit hole questions I want to ask you, but I'm making notes of them because we'll get to them if we get time.

The audience probably isn't as interested in those as I am. We'll get to the meat and potatoes first, and then if we have time, we'll, get to some of that dessert. So I, you're painting this picture for me. You've got 166 women in your mail. Half of them, stress packet, and half of them don't.

And then you have a 60 seven percent decrease in dropout for those that did get the packet. And then you've got this other, it wasn't a, it wasn't a study, but you could at least see in practice from the response rate that you were getting from emailing patients, asking them why they chose not to come back and.

Versus the time when your research assistant was out and didn't send that. So how does, what are the factors as far as you can deduce that impact patient retention? 

[00:24:41] Dr. Alice Domar: it's interesting because at my previous job, I spent about 10 years studying patient retention. And so we ended up interviewing maybe 250 or 300 patients who had insurance coverage.

for six IVF cycles and dropped out and didn't go to a different doctor. They just dropped out. And we asked them why. And most of them said because of communication, either from their physician or someone from the nursing team or whatever. They just had a conversation that just upset them so much.

They realized they couldn't keep up with treatment and they dropped out, which means, as I said, they're probably giving up genetic Parenthood by dropping out. And so then I got on my, my, whatever you want to call it. And I thought, okay, we need to teach people how to communicate more empathically.

And so one thing I've been doing at Inception for the last year is holding dinners for our physicians and teaching them empathic communication. And I do it in a, I don't want to say a mean way because none of them have, we go to dinner and it's, the physicians from the clinic and often the practice, the clinic manager, whatever.

And we, we're at like an ice steakhouse in a private room. And then I talk about empathic communication and all the things that indicate empathic communication. And then I give them vignettes. And I'll have a physician in a difficult situation practicing with either another physician or someone who works in the clinic.

And then I criticize them and it's gone over really well and they've learned there's some insanely easy ways. I, we, we're doing some training videos now at Inception where we just recorded last week training videos on how to communicate the six most difficult conversations that physicians have with patients.

And again, for both scenarios, I talked about how to. communicate empathically. And one of the easiest things you can do is to make eye contact. And so when I was trained in empathic communication, the tagline is never have a conversation with anybody unless you can walk away and tell anybody else what eye color that person had.

[00:27:00] Griffin Jones: Say that again, never make eye contact with anyone, never have a conversation with anyone unless you can walk away. 

[00:27:08] Dr. Alice Domar: So I noticed right away from what I can tell on the computer screen that you have brown eyes, right? Okay, that means I made eye contact with you.

[00:27:16] Griffin Jones: I barely know what color my wife's eyes are.

I'm thinking like, am I that crappy at talking? It's, something that wouldn't occur. Not something that would occur to me to pay attention to necessarily, or I guess better said, I would have to make a point to pay attention to someone's eye color. 

[00:27:37] Dr. Alice Domar: But that's one of the ground, the basis of empathic communication, that when you talk to somebody, especially if it's a physician talking to a patient, they need to make eye contact.

They can't be on their computer. They have to look at the patient and make eye contact. And that has enormous meaning. And if you look at the data coming out of Empathetics, which is an offshoot of Mass General Hospital, they've all this data on the efficacy of empathic communication. When you communicate empathically, patients perceive you spend far more time with them.

One of the number one complaints right now about physicians is that they don't spend enough time with their patients. 

[00:28:17] Griffin Jones: So is, with regard to eye contact specifically, do you find that older physicians are better than younger physicians in that particular regard? Or because I think very often it's said, the older physician is, might be the closer they are to.

[00:28:37] Dr. Alice Domar: That era where the doc was the authority and it was, it's really interesting 'cause I was in Dallas and then Nashville last week recording these physician training videos and we talked a lot about age, like our older reiss, better at communicating, better at being empathic than, for example, fellows. And I think you can't generalize because yeah, older physicians.

Don't tend to look at their computer screen as much because they are more, but some of them are maybe a little bit stuck in their ways. But, it was interesting. So the way we did these training videos, we had these six scenarios. Like one of them was, how to tell a patient that she was miscarrying.

she just had a prenatal scan. There's no heartbeat. And so for each physician, we had them record a non empathic interaction. Or an, a non compassionate one and then a good one. And we had, either, like usually it was an employee of the clinic acting as the patient. And even though it was fake, obviously the employees would say to me, wow, like I could viscerally feel different when the physician was talking to me in a cold, aloof way versus when they were making eye contact and leaning forward and not crossing their arms and things like that.

Millennials demand. Patient centered care. 

[00:29:59] Griffin Jones: Tell us a little bit about some of the gentle corrections that you made, some of those specifics. you told us about, about making eye contact and the way people pose, but what are a couple of specific things that you've said to people? 

[00:30:12] Dr. Alice Domar: I know, one of the most difficult conversations for physicians is telling a patient that she's above their BMI cutoff.

And the instinct for a physician would be to say, I'm really sorry to tell you, if, again, if I'm sitting behind them and they know they're being empathic, they say, I'm so sorry to tell you, but, your BMI is too high. I'm going to refer you to a nutritionist so you can lose weight.

and get your BMI below the cutoff, then you can do IVF. And that is an effective conversation. If I hear them do that, I would probably say, okay, so maybe we could do it a different way. how about, how would you feel if you said to the patient, something to this effect, there are a lot of things that can contribute to IVF success.

And we, I, the lab, everybody, we're doing everything we can to increase the chances that your next Psycho will lead to a healthy pregnancy and there are some things that you can also do that can increase or decrease your chances and one of the things that we look at is lifestyle habits and you're doing great with this and this but you know your BMI is a little high so how about we talk about ways that you can eat more healthfully to get your BMI below the cutoff so you can move ahead and do IVF.

No, which way would you rather hear it? 

[00:31:35] Griffin Jones: my, my preference is probably contrary to how a lot of people want to hear it. But it, the point is that it's not what you say. It's what people hear. And I remember when we were doing online reviews for fertility clinics or helping them with their online.

reputation management, I would look at the reviews and I would see very often she called me fat. He called me old. And I'm like, I wasn't in there. I wasn't in the consult room. I know that person. I don't think. I doubt, maybe she did, but I don't think she did. I think that she said something that in a vulnerable state was too close, too readily interpretable as I'm fat or I'm older, I'm not good enough in some way.

And, so I think that communication is clutch to be able to do. You have to be able to communicate in that way. And that was always something that And when we would help docs with this, it's I can't help you with that part. And so you're starting to. And so you're starting to do dinners. Is there plans to scale this, like beyond dinners and having this be like something that every doc goes through?

[00:32:44] Dr. Alice Domar: I think that's why we're doing the training videos because it's really, we have clinics. It's all over the US and Canada. And so having me go to every single clinic and do this and, not every physician can make every dinner. So it just seems more practical for us to do these training videos.

And I felt that, it was so interesting last week when we were doing them again, hearing the impressions of for one of the training videos in Dallas. the physician's MA was her patient. And she told us later that, she was faking it. She wasn't an infertility patient. She was probably, way too young for that.

And she said, when the physician spoke to her in a classic, somewhat detached, very factual manner, that she felt herself just feeling Like this doctor doesn't really care about me. And then when the physician followed through with all the empathic training and the skillset she has in communicating, the MA was like, I felt different.

I could feel myself reacting to how this physician was communicating with me. And it's, it's not hard. And it saves time, it's interesting because, Liz Grill, she and I once a year teach a course on a cruise ship for physician burnout prevention. And it's actually really fun. We get to go on a cruise together.

And one of the things that I, teach, one of the classes I teach for that course is empathic communication. And the physicians, these are not REIs, these are, all kinds of physicians and they come in yeah, blah, blah, blah. And then I list all the data on empathic communication. And it makes sense.

[00:34:26] Griffin Jones: It just makes sense. So I want to, bridge these two things because, and I don't want easy answers because sometimes people give me easy answers when I'm trying to reconcile the tension between patient burnout and, patient fatigue and, the needs that patients have versus the needs that staff and providers have.

And the answer that a lot of. Leaders give me ally is, oh, they're both, they both have the same interests. They both wanna do great. It's like bull crap that they don't have interests that are at odds sometimes. I'm not saying there's no way of being able to align their interests, but I'm saying that it, when you have patience that have certain demands that costs something on you when you're trying to, be able to deliver that.

And we could make patients really, happy if we answered their calls all at all times of the day and, like sped, didn't have dinner with our family to make sure we got them what they wanted. And, but then, Providers and staff are facing the burnout on that side.

And, you talked about inception a lot of who's your employer, but they are not a feature sponsor of this podcast episodes, which means they don't have editorial control. So you can say whatever the heck you want about them, your own consequences, consider those, but on my show, I don't have to do a damn thing.

I think one of their brands is, the brought to you by a sponsor, but. They don't get, they don't get editorial control. So how do you reconcile this, the needs that patients have versus the needs that the people providing those needs have? 

[00:36:10] Dr. Alice Domar: when I got to Inception, as I said, almost two years ago, it was a little overwhelming because they have almost 2, 000 employees.

And I don't know, at any given time, what, 100, 000 patients. And so I was trying to think through Where would I start? And it's, and I still say this, it's very obvious. You have to start with decreasing patient distress, because if you can decrease patient distress, patients will be easier to work with, and that decreases employee stress.

So I've spent a lot more time trying to design ways. To make our patients have less psychological pain because that will then have a domino effect and make it easier for the employees. 

[00:36:52] Griffin Jones: How do you incentivize the employees to do that when they're already feeling burned out? So if, one of the things that de stresses patients is maybe either more communication about finances or more communication about some of the things that you need and you could even come up with scalable ideas like Modules for the patients, but that takes staff time and provider time, and you have to take some of those staff and providers away to do that.

how do you incentivize the staff and the providers to say, listen, I know you've got needs here, but if we don't de stress the patients, then your needs are only, the burden on your needs is only going to get worse. 

[00:37:37] Dr. Alice Domar: it's, a separate thing because I provide a lot of entities for patients and for employees.

And so I feel like it's, on me to do that. obviously teaching empathic communication is a good thing, but for example, I've spent the last year and a half going to our clinics. I think I have three more to schedule and I do what I call a stress lunch at each clinic. And most of it is talking to them.

about where infertility patients are coming from, about how depressed they are, how anxious they are, how it impacts every area of their lives. And I talk about the unbelievable jealousy they have when anyone else gets pregnant and how agonizing that is and how hard it is to be part of a partnership.

where two members of the couple don't feel the same way at the same time and that puts them into crisis and their sex life goes to pot and they can't go home for holidays because their sister or brother has a baby and they can't be in the same room as the baby and you know I think when you explain to them where patients are coming from and why they seem so demanding and irrational and everything else it makes it easier to care for the patients because they then understand the patients.

It's different from pretty much any other aspect of medicine. You have a patient population who are as depressed and anxious as cancer patients and AIDS patients and heart disease patients, but they're young and healthy. And so when I talk about where patients are coming from and what their triggers are, I think it helps the employees because then you have compassion because you understand.

[00:39:16] Griffin Jones: I think that I could benefit from something similar in my own business and a lot of businesses could. benefit from something similar where you're training your team. This is what our user on the other side, whether it's a customer or a client or a patient is going through on this side, and I think that allows them to take better care of the patient that or the customer or the client That that reduces the burden on the team. I think that could be. I think that I think you have threaded the needle in that way. It still starts with the end user and it starts with educating your team. But if your team is educated on the needs. Of the user, then they can, in this case, the patient, they can reduce, the amount of stress that comes their way down the pipeline.

[00:40:09] Dr. Alice Domar: But it goes, I do a lot of couples counseling. I still have a small private practice. And I think the key with couples counseling is your partner can't read your mind. And you guys are not going to feel the same way about things. And you have to distinguish between what they. Can't do versus what they won't do and so the key to a successful relationship in any relationship is learning to understand Where the other person is coming from whether it be a marriage or a parent and child or being a nurse or doctor in a Fertility clinic you have to understand where the other person is coming from and what their triggers are 

[00:40:49] Griffin Jones: I think sometimes it goes too far one way and like in 2021, it was like, this is what employees need.

And, but then you had a bunch of employers get burned out. It's always, whenever you have more than one person, it's not just what wives want or what husbands want. It's wives and husbands or husbands and wives, whoever it may be, employees and employers. I think that's a really good point.

I guess some of the, I wonder, do you see. Is it helping in a way where you're starting to see turning the corner for reducing the stress in providers? Because I think of the companies that used to be really good at knowing what the customers needs were and servicing them. I think of companies like Apple.

I think of companies like Southwest. I think of companies like Trader Joe's. And I think with the exception of Trader Joe's. They have decreased. you go into the Apple store and they are not as nice as they were five years ago. And I think it's perhaps like what you're talking about. It's a two way street, and that niceness has been presumed upon too much.

[00:41:57] Dr. Alice Domar: But see, that's why every company needs a chief compassion officer. 

[00:42:01] Griffin Jones: Yeah, maybe. I really think so, because you're able to come in and balance this. And how are the providers responding to that piece of it? 

[00:42:11] Dr. Alice Domar: I have to say, I think I have probably met 95 percent of Inception's physicians, I'm guessing. And they've been lovely.

Like, really lovely. Like when I go to clinics, they hug me pretty consistently. And as I said, when I started doing these empathy dinners, I thought I was putting myself out there. I'm putting my neck on the chopping block and they've responded really, well. And it's been so much better and so much easier and so much more rewarding for me working with these physicians, because, as I said, they went into medicine to care for their patients and, some of them are, it's harder to work with millennials who are like, I was here at 730, where are my blood results?

And so I think, you They also respect the fact that I'm a researcher, and so when I talk about stuff, I don't just say this is what I think. I'll cite 16 different research projects that are randomized controlled studies that have been published in peer reviewed journals back up what I'm saying, and that's what you have to do.

You have to, you can't just pontificate what your thoughts and feelings are. You have to back it up with science, especially in this field. 

[00:43:26] Griffin Jones: Is the retention and dropout for third party a different animal? Does it all fold into this, but is, or is there something else that needs to be considered for retaining patients in such a way that allows them to then move on to third party IVF after failed cycles if they need it?

[00:43:46] Dr. Alice Domar: the transition from, for example, cycling with one who owns eggs to egg donor, when you transition from, treatment with each partner's eggs or sperm and the woman carrying that embryo that they've created, that's a different animal than third party because then you get into big bucks and a lot of mourning and grieving, excuse me, that is involved.

I think most clinics or all clinics follow ASRM guidelines. Or that those patients all have to see a mental health professional to, or hopefully they do, to help them process. Because you can't just say, Oh, my cycle didn't work. Let's do egg donation next month. You can't do that. So I think at some level, these third party patients can be more challenging to work with because the financial stakes are so high.

And because a lot of them have moved into it before they're really ready. And so they can be prickly. So there, there are a couple of things. On the other hand, they're highly motivated, but it's tough. I think third party is almost like a different kind of patient population. 

[00:44:56] Griffin Jones: Yeah, I think so. Are there special interventions that you've noticed for them, like, the sending of the email to, to ask why they didn't come back?

Is there anything equivalent to that you've noticed with third party? 

[00:45:09] Dr. Alice Domar: It's been very little research. It's interesting because I'm about to submit a grant for the first time. No one ever has looked at this, is what about patients who come in who want to electively freeze their eggs? Because when patients come in for that first consult, half of them don't come back.

And we're going to be doing an inter, hopefully if it's funded, an intervention site to see if we can better support them. Because what the research shows is women who freeze their eggs, very few of them regret freezing. Women who don't freeze their eggs, the majority regret not freezing. And so again, I as a psychologist want to see what can we do to support these women to make the decision that they are least likely to regret.

[00:45:54] Griffin Jones: I want to ask you the rabbit hole questions of where psychology meets neuroscience, but people would be less interested in that. And you got to go. But if people see us talking, sitting down at a bench someplace at the next conference, that's what I'm asking Allie about. Allie, I wanted you to conclude based on how you would like to conclude about empathic communication, about reducing dropout and increasing patient retention for either providers or staff or any of the threads that we talked about today.

How would you like to conclude? 

[00:46:28] Dr. Alice Domar: I think we all need to accept the fact that patients need to be cared for in a different way than they needed to be cared for 20, 30 years ago. That we have to learn, as you said at the beginning, what patient centered care is. But it starts with empathic communication. 

[00:46:47] Griffin Jones: Dr. Allie Domar, thank you so much for coming back on the Inside Reproductive Health Podcast. 

[00:46:53] Dr. Alice Domar: My pleasure. Always happy to see you. 

[00:46:56] Sponsor: This episode was brought to you by Prelude Fertility, where top REI physicians find their calling. Practice anywhere with Prelude. The Prelude Network is the fastest growing network of fertility clinics in North America.

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Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser. Thank you for listening to Inside Reproductive health.

213 Projecting IVF Personnel Needs. Recruitment, Retention, and Training with Dr. Eric Widra

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


The job market is red hot! There are more jobs open than people to fill them, true for the broader economy and just as true for the fertility field.

Dr. Eric Widra, Senior Partner at Shady Grove, talks through his experience with recruiting and training personnel, and how to project future needs.

Dr. Widra discusses:

  • The need for Human Resources (And the risks they mitigate or eliminate)

  • When to listen to what HR says you need (But also when to push back)

  • Redundancy and cross training personnel (The appropriate levels to have)

  • Adopting technology to automate and augment tasks (While eliminating others)

  • Individual job training (And when company culture training becomes important)

  • The “Godsend” technology solution that’s made the workload and workflow of his financial counselors a lot more efficient.


Dr. Eric Widra
Shady Grove Fertility
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US Fertility
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Transcript

[00:00:00] Dr. Eric Widra: We've often asked the question, should this be, should we outsource this or should we own it? And, outsourcing can be very effective, especially for medium and smaller practices because you just pay for what you need. And so you're not bringing on, long term overhead in terms of the staff and you're still getting, the, expertise that you need.

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Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser.

[00:01:19] Griffin Jones: Hot. The job market is still red hot. There are more jobs open than there are people to fill them. True for the broader economy, you know it at a cellular level if you operate a fertility center. My guest is Dr. Eric Widra. Eric is a senior partner at Shady Grove. I should have asked him for the latest headcount in both doctors and employees for both Shady Grove and US Fertility. Shoulda, coulda, woulda. Suffice it to say, they've hired a lot of people. We talk about how to train, recruit personnel, and project future personnel needs. That means adopting technology to eliminate certain tasks, automate others, and augment others. And it also means good old fashioned HR. I take us a little bit more down the second bucket in this conversation.

Partly because Dr. Widra said something to the effect of, I never knew how badly I needed HR until I had it. That resonated with my own experience. Eric talks about the gaps in recruitment that HR eliminates. He talks about the risks that they eliminate or at least mitigate. It gives general benchmarks for shady growth, staffing ratios, nurse to physician, average IVF cycles, numbers for each.

We talk about redundancy and cross training. What's the appropriate level to have? When do you listen to what HR tells you need? When might you have to push back? We talk about individual job training versus at what organization size do you need a company? culture training. Think of the Disney example.

We talk about the downward pressure for reimbursement in healthcare, what that means for projecting the needs of advanced practice providers. Dr. Widra believes they should be the first line of evaluation for fertility patients, and he explains why. And finally, he shares a technological solution that is almost a godsend that has made the workload and workflow of the financial counselors a lot more efficient.

Enjoy this conversation about training, recruiting, and projecting personnel needs with Dr. Eric Widra. Dr. Widra, Eric, welcome to the Inside Reproductive Health podcast. 

[00:03:10] Dr. Eric Widra: Thanks. It's a pleasure to be here, Griffin.

[00:03:12] Griffin Jones: I was interested in having you on as a speaker because I saw two of your talks at PCRS. One was about negotiating a contract, and I had originally thought about approaching you for that topic for this episode.

But you also did one about projecting staff levels, about meetings, staff, and filling positions. And I Want to go that route first because I think people are still struggling with it. It seemed like this came on as it's always been a challenge, right? But, then, but, then 2020, end of 2020, it really became a challenge.

2021 was really hard for people. 2022 was really hard for people. You sit at Shady Grove, which is a large organization across multiple. Dates was, which is a part of a larger organization in us. Fertility is in even more states and even more companies in your estimation is, the, challenge in retaining and filling seats as hard as it was in the peak of 2022, is it starting to calm down a bit or not?

[00:04:23] Dr. Eric Widra: It depends on what category you're talking about. and I, the fact that we are, large and diverse organization in my mind doesn't limit the challenges, to just those types of places. I think everywhere, everyone I talk to is still struggling quite a bit with attracting, retaining talent in the right seats.

One of the things that I think we've seen ease a bit. post pandemic, if we're allowed to call it post pandemic yet, is that a little less transition and turnover. And some of the clinical staff, specifically nurses and medical assistants, things like that is still a challenge. There's a huge fight to get nurses because of what hospitals are, paying them.

But people seem a little bit more willing to Come to work and sit in their chair and not be looking at the next thing as much as they were. On the, physician and embryology side. Yeah, this market is hot. And I think that there are, there are real challenges for us to not just address this on the staffing side, but address it on the technology side.

Like what can we do to be more efficient and. Utilize the staff that we have without killing them. 

[00:05:41] Griffin Jones: So I want to talk about the technology solutions because that's where I've found the conversations going. Each time we talk about the personnel issue, because it seems like it's the only way to solve the personnel issue that you have to reduce workload.

You have to make things more efficient, that different people can do more things because more. They have the assistance of technology or you're eliminating workflow because it can be automated. It is technology. The only solution is there an HR or management solution to this? And if so, how much is at play versus how much of this is, we just have to figure out a way to eliminate more things and give people more automated help.

[00:06:35] Dr. Eric Widra: Well, I think it's both. And, for anyone who's listening here, who isn't part of a gazillion doctor practice, I make the comment all the time. I didn't know I needed an HR department until I had one. And while, practices of varying sizes may not have that in house, there is a whole group.

Body of work and body of knowledge around HR. That's developed over the years that helps to identify and measure the needs you have and how you fill those needs. And, as an intro to the answer to your question, I think that, yeah, I think there are management. Tools that can be used to rationalize, the people you need and retain them and attract them.

But I think healthcare in general, and because so much of infertility is still in smaller practices, I think we underutilize technology more than many other areas of commerce. the, I've signed up for product services and healthcare online where I've interacted with a bot and my needs were met.

In terms of, scheduling something or onboarding a, a patient to the practice. And in some ways it was more organized. Like we didn't go down tangents. It's Hey, do you need this or do you need that? Are you this or are you that? I just use that as a, as an example. And

I think if you look at every level of the experience of a patient coming through a fertility center and our Struggling to meet their needs. There are opportunities for technology, but it's not the only answer. bringing a patient in, that's one example. Sharing medical records and filling out the forms and the paperwork.

I think that's still a disaster in healthcare in the U. S. and I think it's right for people to come up with solutions to that. And people are working on this. It's just, how does it filter in, how do you use technology for education? I think that's a huge piece of this because so much education falls on the nursing teams and they've got to do their workflow, right?

Which is make sure the doctor reviews the results, make sure you communicate those results to the patients and that it's done with high fidelity and that they follow and they get scheduled. there's all these workflow steps that the more we can automate, the better we are. And I think it's coming, but it comes in.

And first it's a very long answer to your question 

[00:09:12] Griffin Jones: i want to go into some of these technological births that might be useful you said something that i don't think is a throwaway statement i agreed with it wholeheartedly from my own experience that you didn't know how important it was to have an hr team until you had one tell us more about that what do you mean specifically by that.

[00:09:37] Dr. Eric Widra: presumably we're all growing a little bit, whether that's, very rapidly or slowly and that growth comes with real challenges in, your people and your human resources and the ability of a doctor or two doctors or five doctors and a office manager or supervisor to manage that over time leaves a lot of gaps.

It leaves gaps in. Evaluating the credentials of the people who are applying because you're just you're saying, Hey, this is what I think I need, and you might be right. You might be wrong. Doctors are notorious for having an opinion about everything, whether it's correct or not. And in many cases, it's I think I need this.

in health care, there are measurements that people take about What types of credentials perform in what environment the best and that an infertility medicine is not Immune to that we can figure this stuff out the other thing that HR does is it is it takes away risk and we live in an environment where In good ways and in bad ways, we're very sensitized to how we talk to each other and having an intermediary there when that conversation might not be perceived on either end is appropriate, is huge.

And so I think that there are layers. I think layer 1 is the HR professionals can help you identify. By having a broader view who you need for what role they can help you recruit that more effectively, and then they can minimize. Risk and conflict later by making sure the rules are clear, right? So I don't care how many staff you have, if they think they're supposed to be doing X, you think they're supposed to be doing Y.

Somebody's got to reconcile that and having a good set of rules up front and job descriptions and things like that sound. Very pedestrian, but they make a big difference. 

[00:11:43] Griffin Jones: Some of the people listening will work for organizations much larger than yours. Some will work for teams even smaller than mine, but many of the people listening are somewhere in between.

And so for. Many of them, they might be listening and say, that's easy for you to say, Woodrow. You work for the largest fertility clinic group in the country and now one of the, largest networks. and so there you have this HR infrastructure. I would have thought that way. I, a little more than a year ago until I realized, wait a minute, we live in a.

part time remote world and I can hire a part time remote HR person and then I can hire more part time HR people and it has, it's been dramatically life changing for me and someday I'm going to write a book about delegating to outcome and the importance that redundancy and the HR support. play in that.

But people might look at me and say, that's easy for you to say, Jones, you're not in a physical office. You're, you have a remote company. You don't have the regulatory burden of being a healthcare business. What would you say to someone that, that feels that they might not be able to build the type of HR infrastructure that you and I have?

[00:13:07] Dr. Eric Widra: I think you're exactly on the right track there. And I don't think it just applies to H. R. By the way, I think it applies to many aspects of what we do. And in fact, even as large in an organization as we are over the years, we've often asked the question. Should this be it? Should we? Should we outsource this or should we own it?

And, outsourcing can be very effective, especially for medium and smaller practices because you just pay for what you need. And so you're not bringing on, long term overhead in terms of the staff, and you're still getting, the, expertise that you need. And the reality is we live in such a competitive economy that while there's definitely going to be some, mediocre and even poor, Performers in that over time, you're going to find good people who want to do this and are motivated to do And that was redundant, but anyway, you're going to find good, And I think this is true for marketing. It's true for billing. It's true for credentialing for insurance. And as well, it is, however, a very difficult landscape to navigate because everybody's going to tell you. they're best at this and that's where I'm contradicting myself a little bit, but that's the rub, right?

All this stuff is out there, figuring out who's really good at it and who's going to help you. It can be a challenge, but it can be done. And we've done it through our growth in all those areas at different times. 

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That's bundlfertility.com/irh.

[00:15:31] Griffin Jones: one way that I snipped through some of the people saying that they were the best is one of the things that I do now for every single seed is I really think about what that seed is to be responsible for, not just a job description, but what are the outcomes that I'm going to measure them against.

You can't quantify every last outcome, but to the extent that you can try to enumerate them, try to quantify them, try to make them as specific as possible for each outcome. I also identify here's what I think that I have for you to achieve the outcome. This software, this system, this process, this team member, et cetera, and here's what I don't have for you.

To achieve this outcome that you might need. I don't have this software. I don't have this process yet. I don't yet have these team members. And so I, for every single seat, I try to delineate what those are. And then if you do have the opportunity to do some outsourcing, there's, you can. Hire or contract people simultaneously and give them the same or similar assignments and you'll find out who's better at your outcome.

And so that's what I did. I just started with multiple HR folks and then ended up with one that was a good fit that took me to a certain level And then help me get to the next level that I needed for HR help. Is that realistic with fertility clinics when they need some when they have so many bodies in house and they have so many FTEs that are in a physical location?

Is it realistic for them to be able to try out part timers or independent contractors in that way? 

[00:17:15] Dr. Eric Widra: I think there's several things, insights in what you said that are worth touching on. And I feel like we're putting a little bit of a puzzle together here as we talk it through. I think one thing that we do poorly in healthcare is identify what the outcome from that person you want is.

Yeah, embryology is a little bit easier, but come on. The rest of healthcare doesn't have embryos, right? They have, nurses and MAs who need to Do certain tasks. And I think we fail sometimes by pigeonholing them into, skill sets rather than outcomes. And so when I think about onboarding nursing, one of the things I want to understand is, am I hiring somebody?

And I, for anybody who's listening as a patient on this, please forgive the operational nature of this. But, for any nurse that I hire, I want to know how many cycles she can handle, right? Effectively. So yes, she needs the soft skills and the nursing skills to engage with the patients and build those relationships, but she also needs the hard skills.

And if she's not at an appropriate level in terms of that throughput. you've got to make some hard choices. And so I think again, I'm answering the question a little bit differently, but I think both things are true that you should be getting HR that understands that. And I don't know whether it's reasonable to try more than one or not, but I, the, the, but I think that if we're careful about how we invest in this and ask good questions, we're going to make progress.

It doesn't mean you're not going to have errors or wrong fits or things like that. that's life in business. But I think if we're careful about it, just as you said, you're going to, you're going to kick some tires and you're going to figure out what the right fit is. Was that responsive to your question?

[00:19:08] Griffin Jones: Partly. It doesn't totally answer the question. if just by virtue, can you have remote? One of the reasons why I'm able to do this is because I'm an entirely remote company. Have been long before COVID. I've been remote. Since 2012, started building my company in 2015, finally zoom and the voiceover internet protocol videos infrastructure became viable in 2017.

And so we've always been remote. And so that. That I think allows me to play to this advantage where you can start people, you can start many of them as 1099s even when you move them to W2s. And is that, is, are you, is, that not realistic for brick and mortar fertility clinics that have to have bodies in house, even if some of their support staff might be able to be remote?

[00:19:59] Dr. Eric Widra: It depends on the seat, right? yeah, you're not going to draw blood remotely or do ultrasounds remotely, but we have a lot of remote nursing. We have mixed feelings about how effective it is and how to, manage it, but we have tons of remote nursing. I think that a lot of the back office stuff can be remote.

And again, for practices that don't have the size or infrastructure that we have, outsourcing that can be incredibly effective. Your billing, your insurance credentialing, your authorizations. one of the things that I think we're going to need to adapt to is, how do we do those functions?

Because those functions are going to become more important as there's more access to care and more insurance coverage. the rest of healthcare has mostly figured this stuff out and we feel like we have to reinvent it. But, there are software programs out there that automatically do benefits.

They're not perfect, but you don't need three people doing that. You need somebody who manages the software and, we're just starting to wake up to that because we've been in such a unique environment for so long. 

[00:21:05] Griffin Jones: Okay. So it is possible to have the HR support be remote. Oh yeah. That part. 

[00:21:10] Dr. Eric Widra: I, yeah, I think that those types of, I think HR is probably one of the easier ones to be honest because your measurements are easier.

It's I have this many open seats. Are you filling them? And I was, And to your point, are the outcomes from those filled seats what you need them to be? Billing is always nerve wracking because you don't know if you're optimizing it. 

[00:21:31] Griffin Jones: On the outcomes of those seats, you mentioned one example that you want your nurses to be able to do a certain volume of cycles.

Do you put that number in the job description? 

[00:21:46] Dr. Eric Widra: The way we describe it is we have benchmarks for, nursing output in terms of cycles, and we don't necessarily expect a new nurse, especially if she's not coming from fertility, it's almost always she in our specialty, to necessarily meet those benchmarks right away.

So no, we don't put them in the, contract, but it is part of their evaluation. Top of the pyramid nurse. And I actually Griffin don't know the number off the top of my head. So I'm embarrassed to say, but that's because I get to let somebody else do it. this is the benchmark for, a 90th percentile nurse.

This is the benchmark for a 50th percentile nurse. And if you're starting at the 30th percentile, we want to see moving in that direction. 

[00:22:33] Griffin Jones: So that's, I, don't put the numbers in the employment agreement typically, like it's not contingent on, like I'm not that sophisticated yet. Maybe someday there will be some sort of a performance for each of your, I'll do it for you.

Yeah, exactly. Yeah. But for the time being, I do have a separate document. It's not a legally binding document, but it is, useful for expectations that I have. Everyone. Look at and it's a, you're responsible for this many podcast editing, this many podcast episodes per month, you're responsible for this much billing under an account, et cetera.

and then when I can, I do try to put that in the job description and I'll, put. Up to in the, up to a certain amount so that I just want to set the table with anyone that I'm having an interview with that they know this is what I'm expecting of you. I want to set that expectation early and often not have them come in and be like, Oh, this is more than I thought.

And Even when there's a range I'll put the up to. And I find that really useful to start with in the job description while they're still applying. Do you see any reason why fertility centers shouldn't do that? Why they shouldn't put numbers in the job description? Absolutely 

[00:23:50] Dr. Eric Widra: not. And in fact, you just identified a hugely important function of HR, whether that's in house or outsource, which is evaluation and performance.

Reviews, we used to joke all the time that, if, nurse a wasn't performing, she'd go to Dr. X and complain and Dr. X would say, she's great, and you just got to get rid of that. And that's true. Whether you're two doctors or 200. 

[00:24:21] Griffin Jones: And so your talk was about also projecting for needs that I'm, hoping that because you were speaking at PCRS, yours is a little bit more sophisticated than mine is.

What I tend to do is I'll start at a part time level. Usually if it's a new, if it's something new that we're working on or a new area or a less mature part of the business, I'll start just part time and I'll usually Just get somebody at 5 to 15 hours. I'll make my outcomes more sophisticated as, that becomes developed and I'll start normally more junior on the accountability chart than senior and that's how I figure out what I, what, I need and, and.

how much it will cost me. And it's not the most scientific, but it does give me a bit of a measurement. how do you project staff levels? How do you know when it's time to hire a new person versus this doc just says he needs a new nurse when is it, this doc is doing more with less nurses.

[00:25:28] Dr. Eric Widra: And and I think the three areas that we're, we've focused on is, docs, when you need a doc, and I think there's some really interesting things to think about there as our system evolves, embryology nurses, some ways on the wind, you need somebody. Embryology is probably the easiest because what they, the, they, the measurements that they make are very.

it's not squishy. It's you do this many egg retrievals, you do this many PGT cases, you do this many ICSI cases. And over time you start to see, you develop a matrix, if you will, of how many people you need to do those things that does, however, need to be pressure tested with the rest of the world.

And I think that our professional societies actually do a good job on the embryology side of saying, Hey, we think this is a reasonable workload for an embryologist at this level or this level. And practices can take those data and then You know, massage them based on how, what their workflow is like and what their function is like and the capacity of their people.

and because it's the, risks are so high and the outcomes are so obvious, right? You get a baby or you don't. I think it really behooves us to, to be strict about those numbers. And, only adjust them or adapt them if we have really good reason to do And one of the things I see a lot in some of our smaller practices or newer practices are we sometimes make the mistake, it's a mistake.

We sometimes start with more people than we need. Based on those metrics, either because they were there already or we wanted to make sure it was as smooth as possible and then they struggle as with growth and managing that is really important, but I think if we're responsive to the data and the numbers embryology is probably the easiest way to easiest thing to do and nursing.

I think we've talked about a bit. It's Yeah, some docs do more with less and, at some point there's just going to be that human element that you can't measure perfectly because we're not going to turn the docs and, or the nurses for that matter, into robots. 

[00:27:52] Griffin Jones: Do you set a sort of standard as a company of this is how many, this is how many nurses one physician should have or is it, more by volume?

Oh yeah, and we have stuff that we, yeah. 

[00:28:05] Dr. Eric Widra: So it's, both actually. and a lot of our docs are coming out of fellowship. And so they're not bringing a patient base with them and we have, yeah, we have a standard approach to that, which will be okay. new doc is joining me and I'm just making this up, joining my office.

And so we'll hire another nurse and half of her old do Eric and half her new doc and his new dog grows. She can. do that or, cross cover other things, but yeah, we have a, again, it's not a formula I can recite for you and Griffin, but we, yeah, we have formula about that. and basically we start with the mean, and then we decide if somebody is, performing to the left or right of the mean.

So an average SGF doc, probably does, just, Plus or minus 200 egg retrievals a year. And they need two nurses to do that. But it's a pretty, it's not a very tight curve. it's pretty diffuse. 

[00:29:09] Griffin Jones: You mentioned embryology being one of the easier positions to look at the numbers to see where there's need.

Nursing might be in the middle of the road. What about support? What about support staff? What about medical assistants, phlebotomists, down to front desk? How do you, possibly project what you're going to need in those types of roles? 

[00:29:31] Dr. Eric Widra: I gotta tell you, that's HR's job. It's a struggle because there's high turnover in those positions, but, it's not that hard to measure.

You see this many people, between seven and 10 o'clock and, to get them through, you need this many people drawing their blood and doing their ultrasounds. it's not rocket science. 

[00:29:49] Griffin Jones: it might be HR's job to determine the levels that are needed, but there is a business call that's made on the appropriate level of redundancy.

I had David Burford, who's the CEO of Care Fertility on, and I talked about this bec And I thought it was fitting because he's in the UK, where they use the word redundancy to describe layoffs. If you were made redundant, that means you were laid off, and I think Ah, the English in their language,

[00:30:16] Dr. Eric Widra: I love it.

[00:30:17] Griffin Jones: yeah, there's, some poetry in there, and I, think it's a bit revealing because That is why you would do layoffs in a company as if you had multiple people doing similar things to become more efficient. You'd reduce your head count and you'd eliminate redundancy. I have found a necessary level of.

redundancy to, to, reduce burnouts, because if you have a, a certain number of people that are responsible for the total workload of the company, and then that number gets smaller, it becomes harder for the people that are there. And then you start to have more attrition because it's harder and you can't feel fast enough.

So that's one of the reasons why I think redundancy is important. Reason I think is that it's just it's easier to cover for people. It's easier for to plug people in when it's easier to cross train on. Then ultimately, if you have a big enough organization and especially if you have a wider layer at the bottom of the pyramid of junior people, you're, you have a feeder system for, senior people.

And if you, if your middle layer is a bit wider than you, then you've got another layer there. And but that's a business. 

[00:31:35] Dr. Eric Widra: People get sick and take vacation and have babies and all this stuff is just part of managing your business and you need that. Yeah. 

[00:31:42] Griffin Jones: And it's easy for me to make that decision because I'm a, I own 100 percent of the business.

I'm the only managing member. You're in a much larger organization where you have to consider different people's shares and you have fiduciary responsibility to the company and to each other. How do you make that decision at that level of what is the appropriate level of redundancy? 

[00:32:06] Dr. Eric Widra: To be honest, Griffin, I spend almost no time on that, as even in my leadership roles, we really do, we ask HR, what do we need to get this done?

Now, sometimes we'll see some 

[00:32:18] Griffin Jones: And you just do it, whatever HR says? 

[00:32:20] Dr. Eric Widra: Ah, within reason, yeah, but you don't I approach it like I do anything else. The hypothesis is HR is correct, and then we see the data, right? And if the data support the hypothesis, we're good to go. We have absolutely had times. That HR is seem to been just like on a hiring bench and you're like, guys, what are these people doing?

it looks like a lot of people standing around. yes, you need manage, you need input from the physicians and the managers and the office supervisors, but I, yeah, 

[00:32:48] Griffin Jones: I, I think you articulated it pretty well. 

[00:32:51] Dr. Eric Widra: Yeah, you. You are very well. Actually, you start out with what you think makes sense and if it's working and you add or subtract as needed.

I think that in health care, there's a real risk of being too lean in terms of the risk of errors per patient satisfaction. And so I think you're always going to see us error a little bit on the side of having some redundancy. But, we're very active managers at S. G. F. In fact, sometimes as physicians.

In fact, sometimes I think we're in too much in the weeds, but we push HR pretty hard to tell us why they're doing what they're doing and to prove to us that it needs to be done based on some metrics. 

[00:33:33] Griffin Jones: The default is that HR is correct and then you look at the data. What's an, and so most of the time you're going with the recommendations.

What's a specific example where you did push back against HR? 

[00:33:45] Dr. Eric Widra: Yeah. and it gets interesting and complicated, right? Because you and I might think that this job over here would be great for a part time person, but it may be really hard to fill that job with a part time person. In fact, the people who are applying for it as part time may be terrible.

And so you have to make compromises to say, maybe that person does something from 7 to 11, something different from, noon on. But sometimes you, need to really pressure test that we, what's interesting about the way our workflow in a day goes in the clinic is between seven and 11, we're seeing an enormous number of patients who are coming in for their IVF and IUI and other ultrasound and blood work.

And you need to be staffed for that. And these women want to come in and get out the door and get back to their jobs or their, lives. And. You need a lot of bodies to make that happen, but then one of those people do the rest of the day. And so that's been a great example. And one of the tensions we've had over and over again with HR through the years is, you I don't want to be paying somebody to be drinking coffee often, that's not.

That's not good business. And so I think that's one example. and, the reality is the solution to that ebbs and flows with the job market. 

[00:35:08] Griffin Jones: Have you developed a process for cross training to solve for that? Absolutely. Yeah. Tell us about that. 

[00:35:15] Dr. Eric Widra: Yeah, but not every, again, the, simply the volume demands are different.

So yeah, we will take, we'll take an MA who's in monitoring the call in the morning and cross train them to do the instrument prep for the OR the next day. but that presumes that the people who would normally do that are busy all day. So it's, a challenge. I don't have an easy answer for you on that one.

[00:35:40] Griffin Jones: as you're bringing on more folks and the companies get bigger, has there been a change, have you seen a change in, Shady Groves training of the Shady Grove way? So I'm not talking just about this is how you do this particular. role, but rather think of Disney. It doesn't matter if you're, a new VP of business development for a theme park, or if you're someone that washes the grounds of the magic kingdom, everyone goes through a certain level of.

Disney training. This is how we do it here. This is, we point with two fingers. Don't I, don't ever let me catch you pointing with one finger. That's so funny. I didn't know that one. Oh yeah. I still do it to this day, Eric. I point with two fingers whenever I'm pointing somebody in this direction. And so everyone learns a certain bit of Disney culture.

And I'm starting to do that with my company as well. Starting to, here's the inside reproductive health way. This is the fertility bridge way to, to have that cohesion. In addition to here's the training for your particular role. How much level of shady grove training is there? Has it increased? Is it remain the same?

[00:37:00] Dr. Eric Widra: It's big and it's a huge part of what we do. And for better or for worse, it still relies on kind of the ancient apprenticeship model, right? That, you're going to work with this nurse and she's going to teach you how to do this. You're going to work with this MA and this is, you're going to see how, the workflow happens and the way we talk to people and the way we escort them into the room and the things that we say.

And. Now we do, we have what we call it for nursing. We have what we call cohorts. So we've got a whole bunch of nurses that are starting between, month, between the 1st maybe that's 10 nurses. I'm just making that up, but they will all sit together in the same training and that training will be.

electronic and in person. And so we try to acculturate them that way. But then they're going to go and work with a more experienced nurse and, start to really see how to implement those concepts, as they grow their, practice, if you will, of, people that they take care of. we're really expanded our use of advanced practice providers.

And I think that's something worth talking about a little bit before we wrap today. And, we have a, whole protocol for onboarding. Advanced practice providers, and it still is very much here are the leaders of this and they've been here forever and they're going to show you how we do stuff. I can show you how to start an IV or doing all well, we'll teach ultrasound a little bit, but how do we approach problems?

How do we take care of patients? How do we triage? How do we fit in as that intermediary between the patient and the physician? So yeah, there's a lot of that. 

[00:38:36] Griffin Jones: But you're still getting away with doing it at the individual level where each individual mentor is doing that for their team as opposed to like having a cohesive Shady Grove University.

Here's the modules of here's how we do everything so that everyone and not just job training and not just handbook stuff, but like a cultural training. 

[00:38:58] Dr. Eric Widra: It's both. So yeah, like the nursing cohort and that stuff. And we do have, tons of manuals and online stuff that we used to actually call shitty good university, but I think we changed it because everybody called every, company at university after that.

We didn't invent it. Come on. it is, it's a combination, but, I think part of what we're trying to talk about today is, that's what works for us because of our size and complexity, but I think there's that it's critical in any corporation to have a culture that you can teach and transmit to your people.

[00:39:33] Griffin Jones: Yeah, I think I've found out how I thought we were such a small organization we had 20 people on team right now, and it's it's still really important and it would have been important when I had six, and, and I don't think I don't know, maybe two or three is too small, but for the vast majority of the people listening, I don't think it, they can be in too small of organizations in order to start building that cultural training and because they'll, find it very useful as something to point to later.

Yeah, I, agree with you that we should hit on APPs before we wrap. Is there an appropriate staffing ratio to? To, to APPs, how would one even figure that out in a formula because of the different variants of what they do? Is there, and especially as we move to utilizing more APPs, how, do you figure out when you need an APP versus when you need a nurse versus when you need a doc?

[00:40:32] Dr. Eric Widra: Yeah. And call me back in a year and I might have a better answer, but my, my, one of my projects for this year is to address the following pressures. We, have, to our credit, expanded access to care. It's got a long way to go, especially in vulnerable populations, but we're getting there. What that means is the reimbursement for the services is going to have downward pressure.

That's just the way the world works. It's not anything unique to us and the rest of healthcare has lived through this and probably much more. Disruptive ways than we're likely to, in addition, not just because of the price pressure, but just because of the volume pressure, you're going to need to, see more patients per unit time.

And because of the price pressure, you're going to need to do it more efficiently. And I think that the challenge for us is to find a way to get to that perfect or perfect is never going to happen to that correct ratio where you're still providing appropriate levels of service. But triaging that level of service based on what the patient is coming in for.

And so I think, and this is already being done in plenty of places. Bad thing about being this big is it takes time to institute change. But there's lots of places that are like, you use APPs, what do you do with them? I'm like, Whoa. Yeah. So I think. I think that the role of the APP in fertility medicine is definitely going to expand in some places.

They do all kinds of things now, but I think they're going to, they're going to triage new patients. They're going to see new patients and order testing before they get to see a doctor. I think they're going to continue to do more and more hands on stuff, ultrasounds, in office procedures. I've heard people talk about training APPs to do egg retrievals and embryo transfers.

That's a podcast unto itself. I think that's not going to be a very big piece of the puzzle, but the other pieces are going to be critical to maintaining the economics of what we do and the quality of the service we provide to our patients. 

[00:42:42] Griffin Jones: The APP topic is a topic in and of itself, but while we're still on it, you mentioned their role is going to expand.

What are some of the, what is maybe one thing that you feel many APPs are not doing now, or at least they're not doing in a great many places that they could and should be doing, and it's probably the first area in which their role will expand. 

[00:43:04] Dr. Eric Widra: I think that they should be the first line of evaluation for a lot of infertility patients, especially in underserved areas.

the fact that you live somewhere rural and have infertility shouldn't be such a massive burden because so much of what we do is not hands on. hopefully this joke will come across. Okay. I don't do physical exams on my patients. There's just no role for it. Yeah. They get an ultrasound eventually.

Sometimes the first visit, usually not. So I can, if I have an APPU seeing someone in, West Virginia, I'm in DC. And, they're in an underserved area, but the APP is happy to, they can order the stuff. The testing that we do is preliminary, is, straightforward. Anybody can do it. And then, and then I can have a virtual consult with that patient where I can be efficient and also provide a high level of care.

One of my associates, Edward Harton said something interesting to me the other day, we were talking about these challenges. He's the less I know about a patient, the more time I have to spend with it. And while our goal as physicians is not to minimize the time we spend with patients, that's not correct, we do want it to be efficient.

if you called a cancer doctor and said, I think I have cancer. Can I see you? They say, no. until you have a diagnosis and the pathology from the laboratory and all this test done and your imaging done, I'm not going to see you. Because it's not a good use of either of our time.

And so I think that as we move, as we expand access to care, I think you're going to see a little bit more of that. And I'm sure your colleague in the UK had some insights into this. in the UK, you don't see a doctor necessarily, especially in the private sector until you're pretty far down the pipeline.

[00:44:53] Griffin Jones: We're going to bring you back on in a year to talk about how you figured out those ratios, but you've at least given us a preview of what people need to project for as they start to expand their use of APPs. I'm jumping around a little bit, but we I had a thought pop out about training is have you learned any lessons about what absolutely needs to be in included in training?

So what we try to do is lay the process first. We use a project management system, and that's where most of our processes are documented. And then we'll use a software. We're called loom to do video documentation of it. And there's other softwares called train you all. And, other competitors to loom and train you all.

Have you found a bedrock of, about what absolutely needs to be included in every training or how it needs to be structured as, a framework, regardless of what specific role it is. 

[00:45:51] Dr. Eric Widra: It's a great question. And as you mentioned those things, I'm reminded how far we still have to go in terms of using these types of tools for that.

I think that's, that even though I'm proud of the way we train people, it sounds very primitive compared to what you're doing. And I think that's an opportunity for us to get better. But what I do think is the most important in healthcare, especially for what we do, is this acculturation.

That I don't think many of our skill sets are, so narrow that we need to like overtrain for those, the soft part of nursing is the same, whether you're, in a pediatric clinic or an IVF clinic, drawing blood and doing ultrasounds is the technique, the techniques, very little in the patient population, but their technical skills, but getting across the division and the mission and the culture.

Yeah. It's got, to be the most important thing in my mind because that influences not how you draw the blood, but how you interact with the patient and how you value that person's journey and the issues that they bring, that's the key. And I think that one of the things we've been successful at, despite the fact that we're, we were a business and we have to measure things and buy things and give services for revenue, is that we've been able to demonstrate.

That the patient comes first and I think if we can teach that and we can Live that because saying it and doing it are completely different things, right? you can be famous hospital X who says we're the best at this and you can get treated like dirt in the ER and it's all just talk. But if we can live that and show it and keep the people who are able to do that and redundant out the rest, that's the, that, to me is the secret sauce of staffing.

[00:47:46] Griffin Jones: We started the conversation talking about technology and HR as means of in, in being able to recruit more, being able to fill seats, being able to have longer retention. I took us down the HR route more deliberately. I still want to glean, a, second of a technological lesson if I can, is what's an example of in the, since.

Recruiting has gotten as crazy as it has in the last two years of a technology that you've implemented that has either made certain staff more efficient or just taken things off of their work entirely that has been a godsend to you. 

[00:48:29] Dr. Eric Widra: it's happening now. It's not quite at God's end level yet, but I can see it emerging.

So several years ago, we work with a vendor who does our consenting process and it's extremely thorough. It's video based. The patients have to answer questions along the way at the end to demonstrate they actually watched it. So both from a patient education standpoint, a consent standpoint, and a legal standpoint, it's awesome.

And, and, Mike Levy to his credit is like, why are we doing this for our financial counselors? Because we still have a lot of patients who are self pay and we have a whole menu of financial programs depending on the types of treatments they need and that can take a long time to explain.

Especially when you're talking to somebody with the anxiety they have about. Not just, am I going to get pregnant, but can I afford it? So we've made those modules, with our vendor for the financial counseling. And, it's, it was amazing, the resistance to it as there was when we did the consent thing, because people are like, are you taking away my job?

I'm like, no, we're making your job actually easier. 

[00:49:41] Griffin Jones: Because of what Dr. Harriton said, because the less you know, the longer it's going to take. That's also true for the patient. The less they know, the longer it's going to take. Yeah, and for the 

[00:49:51] Dr. Eric Widra: financial counselor. Yeah, a hundred percent. And so I see that as a great use of an adaptation of technology that, was staring us in the face.

[00:50:01] Griffin Jones: There you go, EngagedMD. That's your new slogan for your website. Almost at GodSend level, you can It's a free one from Eric Widra and I. you have the final thought, Eric, whether it's something from your talk at PCRS that I didn't ask you about. If it's just something else about how to train, recruit personnel, projecting personnel needs in the future.

How would you like to conclude? 

[00:50:26] Dr. Eric Widra: Thanks. I, it's great. I, the, horse that I've been riding lately is we have to adapt to the world is changing around. This is changing faster than we think. And we, need to be open to that. Physicians, especially hate change. What we need to do is get ahead of the things that are going to affect the way we deliver care.

And that means being open minded about the role of different providers. One of my, I stole this line from somebody, it's very businessy, but we want everybody working at the top of their license or their credential. I think that, but that makes a lot of sense, me explaining how the menstrual cycle works.

Probably not at the top of my license explaining how IVF and PGT works. Yeah, that's my job and being open to technologies that can streamline things for us. And that's a two edged sword because some technologies are better at it than others. But once again, your comments before left me like, Oh wow, there's still stuff out there we don't even look at.

So I hope that was a cogent closing comment. It

[00:51:30] Griffin Jones: was, and as much as there's more to look at, I'm still looking at more of it, too. I say that I'll write a New York Times bestseller once I'm a black belt at all of this. And I'm a yellow belt right now. I'm a yellow belt right now, orange belt at best. But someday you'll see it in the airport, and I'll send you a free copy, Eric, because I'm thankful to you for coming on the Inside Reproductive Health podcast.

Thanks for coming on. 

[00:51:56] Dr. Eric Widra: Thanks for having me, Griffin. Have a great weekend.

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212 Exponential Impact: For Young Fertility Doctors to Consider When Choosing Cities with Dr. Zachary Walker

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


Could your impact as an REI be magnified by where you live and practice?

3rd-year REI Fellow Dr. Zachary Walker shares his strategies for creating an impactful career, outlining where and how he intends to contribute to the fertility community.

With Dr. Walker we discuss:

  • Promoting diversity among patients, providers, and outcomes (And research needed in those areas)

  • Income versus cost of living for REIs (Big cities vs. small)

  • Establishing REI Fellowships in states without existing programs

  • Talking about access to broader IVF care versus providing it


Dr. Zachary Walker
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Transcript

[00:00:00] Dr. Zachary Walker: I think the more we can start to push this agenda to current fellows that going to, I would say, these rural areas, not technically rural, but to service a population is definitely needed to improve access to care. And I think with my background of going from Indiana to Birmingham, Alabama to Boston, I've seen all different types of populations, cultures, and it's not very shocking to me to be able to practice in a place that may not be.

The most conducive or liberal to reproductive health, but feel comfortable being able to provide that care that's needed. 

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Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you, but the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser.

The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser.

[00:01:37] Griffin Jones: Exponential impact. As a graduating REI fellow, as a young fertility doc, as any fertility doc, you're going to have an impact. Could that impact be magnified if by no other factor than where you live in practice? I explore that concept in my conversation today with Dr. Zachary Walker. He's a third year REI fellow, and he's not moving from Indiana to Boston.

He's going the other way. Zach talks about what he wants to accomplish in practice to promote diversity among patients, providers, and outcomes, to do research in those areas, and to help to launch an REI fellowship in a state where one currently doesn't exist. Consider that for a second. It's one thing to say that we need more REI fellowship.

It's another thing to say, I'm going to move to this area and try to start one in this specific location with this specific institution. We talk about that. What's the difference between saying we want broader access to care versus actually providing broader access to care? We talk about the proportionality in income to cost of living for REIs in big cities and REIs in small cities.

And we talk about a relationship between the clinic and the lab, which might either be really complicated or might be a totally new and beneficial way. For Reis to diversify their business interests. This conversation was a lot of fun. If you're recruiting Reis or if you're an REI looking for the next chapter, I think you're really gonna enjoy this conversation with Dr. Zachary Walker. Dr. Walker. Zach, welcome to the Inside Reproductive Health Podcast. 

[00:03:00] Dr. Zachary Walker: Thank you. Thank you for having me, Griffin. This is amazing. I'm happy to be here. 

[00:03:04] Griffin Jones: Finally, I get to talk about a topic that I've probed at different times with graduating fellows, with younger docs, with some of the execs, where I'm really curious about how we expand access to care geographically.

I'm from a small city. I live in upstate New York. There's lots of Buffalo, New York, and lots of Akron, Ohio's and lots of Indianapolis, Indiana's and it seems to me like 80 percent of the graduating REIs go to 10 or 20 cities. And maybe it's not that uneven of a distribution, but it just seems like there's a lot of people going to the Bay.

There's a lot of people going to New York and Boston and L. A. and It seems like that the smaller markets are not getting their fair share. And so when we talk about access to care, we talk about a financial level. Can people pay for it at a technological level, the demographics that we're serving, all valid pillars of access to care.

The geographic one, I think is really important because until we all live in the metaverse, you got to see people in your area. And I was when I ran into you last and you told me that you were going to. Practice in the Indianapolis area after fellowship. I thought maybe this is the guy to talk about this topic with.

So let's just maybe you're a third year fellow right now. And so you're going to practice in the Indianapolis area next year that we're recording right now in January of 24.

[00:04:33] Dr. Zachary Walker: I started in August of this year. 

[00:04:36] Griffin Jones: So Tell us about how this came to be. 

[00:04:41] Dr. Zachary Walker: Yeah. So it was somewhat of a, I would say like a roundabout journey.

Initially, my thoughts were to, as you kind of alluded to, most people stay in kind of bigger cities during fellowship. So my plan was to stay academics and I was going to stay at Brigham and Women's Hospital in Boston, Massachusetts, where I am now in fellowship. And then things started to happen with my family, both me and my partner's family are both older, so they're getting thicker.

So we. And we also wanted to build our family, so it seemed that staying in the Boston area may not be the most conducive to our future as far as family building and being able to be there for our family because both of our families are very far away from Boston. I interviewed at different places, so I interviewed back and At my residency at University of Alabama in Birmingham.

I also interviewed at Indiana University, which is the academic institution in Indiana, and then also the private practices in Indiana as well. And then before I moved from Boston, I also interviewed at the private practice in Boston CCRM. Initially, my plans were to stay in the academic kind of realm, so I interviewed at Indiana University School of Medicine, and their school there does, they don't have a IVF lab, so they are partnered, at the time when I was interviewing it, with two different private practices to send their residents to get the experience with IVF.

And as a referral base, it's one of them being a Midwest Fertility Specialist, which I've signed with. And then another one being Indiana Fertility Institute, which is really close to the Midwest Fertility Specialist Practice. So I interviewed at both, and they both had their kind of pros and cons, but ultimately, I think we'll get to this in a little bit, but the Midwest Fertility Specialist Practice just felt more like home and really felt comfortable moving into that realm after fellowship.

So that's where I've decided to move forward after fellowship and continue learning and growing in that space. 

[00:06:39] Griffin Jones: There's a lot of people that live in Boston and places like Boston where places like Indianapolis are nowhere in their narrative. How readily did you accept this and just say, okay, my partner's from here and so I'm, I'm down.

Or how much of it was like like a pill you had to swallow? Tell us about that. 

[00:06:59] Dr. Zachary Walker: It was a very easy pill to swallow. I mean, I did medical school in Indiana, so I was familiar with the terrain. And if you ask any of my friends from medical school, they are very shocked that I'm coming back to Indiana because it was a very cold environment and I didn't see myself being there for a very long time, but then I met my now partner and I started to fall in love with the area more and most of my mentors from medical school are still there.

So when I interviewed, it was. It's like coming back home a little bit. So the foresight of me being back in Indiana has become more clear. And I feel like, as you alluded to before, the need is still there as far as REI in terms of how many providers are in the area. Basically the Midwest Fertility Practice and the Indiana Fertility Institute are the biggest two groups.

They are serving this IVF need. So patients are coming from all over the state to get their IVF in that area. Yeah. I think the more we can start to push this agenda to current fellows that going to, I would say, these rural areas, not technically rural, but to service a population is definitely needed to improve access to care.

And I think with my background of going from Indiana to Birmingham, Alabama to Boston, I've seen all different types of populations, cultures, and it's not very shocking to me to be able to practice in a place that may not be. The most conducive or liberal to reproductive health, but feel comfortable being able to provide that care that's needed.

[00:08:27] Griffin Jones: So when you say cold, do you mean culturally or you mean like it's chilly, like climate wise, it's a cold place to be. So you had this experience from medical school. Did you meet your partner in medical school in Indiana? 

[00:08:40] Dr. Zachary Walker: Yeah, so me and my husband, I met when I was a medical student in Indiana.

He works, he was working as a, in a restaurant as a bartender and we met and then things just kind of took off from there and he's been on this whole residency training journey with me since then, moving with me to Alabama, then to Boston. So yeah. 

[00:09:01] Griffin Jones: Had you met in Boston or somewhere else and you hadn't ever had that experience of living in Alabama, of living in Indiana, but particularly Indiana because that's where you're going back to, would you have considered it as 

readily?

[00:09:15] Dr. Zachary Walker: I think I would. I, The appeal of being in a big city, I mean, it's nice because of just the fact you have things to do and Kind of a accessible place, but definitely I grew up in a somewhat of a small town. I grew up in Hampton, Newport, East Virginia, which isn't like a big city. It's filled with military families and pretty much a lot of people know one another's close knit community.

So the attractiveness of moving to a big city, wasn't really top of my priority list. Mainly I just wanted to be at a place that would allow me to continue to grow and allow me to feel comfortable. to practice and to live and build a family, and that was the most important thing. So regardless of where we met, I think I would have still considered moving to smaller cities or outside of the, like the major network.

[00:10:03] Griffin Jones: Appreciate the distinction that you're drawing between smaller cities and rural because a place like Indianapolis is rural to someone from LA, but in the grand scheme of things, like I lived In the heart of South America in the country, two and a half hours from the city. And I had to hitchhike to the road to get to the main road, to hitchhike again, to get to the closest small town, right?

Like there's rural and then there's just small cities, which is. Which is like what an Indianapolis or a Buffalo is or a whole lot of places that are Tucson, Arizona that are really nice to live. And I think it's an important distinction to make because, unfortunately, the patient population that it does live in the rural areas is still driving to those small cities to, to the provider in many cases.

There are some people that are out in North Dakota and they're going to really, rural areas. But for the most part, when we talk about these small cities, we're talking about places that, sorry, you're going to have to take a connecting flight to ass around when it's in New Orleans.

I know that sucks. Like I want to take a direct flight too, but you know, you, you lose out on your direct flights. You lose out on. That your three star Michelin restaurants you, but for the most part in you, you talked about this in the beginning where your interest is in building a family and having a family, like you're a busy provider.

You're gonna be a busy husband and dad like. How many three star Michelin restaurants are you going to in a month anyway? Like, you'll go there when you go to New York, like, I will go to the nice restaurants when I'm in Toronto, in L. A. And then in the meantime, I'll just be a dad, work out, and work my tail off, and then not have time for anything else anyway.

So Correct. Do you think about this, though? Do you think about what amenities you're giving up, and what amenities you're 

[00:12:01] Dr. Zachary Walker: Yeah, I mean, we've been in Boston for the past three years, and me and my husband we go out, but it's not like a often thing, like every weekend, we're not going to like see a show or going to explore the city.

We are very much homebodies. And that's just me personally. So I can't speak with everybody that lives in a bigger city. But giving up those, I guess, amenities isn't a big deal. Because like you said, there's You're, there are always going to be times where you're going to go on vacation or you're going to go out and make time to do those things that you really want to do and they're not something that I do on a regular basis.

I mean, I think some of it might be a little bit overrated for me, but the small city to big city life is probably going to be very much the same in terms of what I access and did on a regular basis. 

[00:12:49] Griffin Jones: And, there are some people that I know, I've talked to some REIs that they practice in Midtown Manhattan, and they live in Midtown Manhattan, and that walk through Midtown is part of their day, it's like part of their essence, I get it, there are some people who having access to those amenities is really part of their life, I think for 80 percent of the folks Who often clinging to that.

It's like, how often do you really use it? And when you're a top one percenter, as most of the people listening are, or at least the top five, top 10% or earner, it's like, you can do that whenever you want, like especially have, did you look at like the delta in between, you know what? R. E.

I. s are making in some of these coastal cities and what they're making in some of the smaller cities. And then also the delta in cost of living, like they're not, how equal are they? 

[00:13:43] Dr. Zachary Walker: Like, yeah, it's, I, so I've looked at some of my other colleagues who have in my year who are have signed and moved to different cities.

Some of them are. Moving to like smaller cities, like, I think some people were considering moving to places in Tennessee and, or places like smaller cities in Texas. And definitely the cost of living is the part that is the kind of gets you as far as like the sign on bonus that they may offer you or how they do their bonus structure and living in Boston, like coming from Birmingham, Alabama, where me and my partner had a house, our mortgage was.

Like, like in the 500, they're moving to an apartment in Boston, spending, spending over like 3, 000 for an apartment. It's crazy, insane, but definitely you get that inflation in your salary that makes it seem like, Oh, I'm making a lot more money. The most that is coming out of your paycheck every month that you would have had to use to spend if you were in a lower cost kind of city.

So I think the contracts or the salaries that are being offered are pretty comparable. Throughout the states in terms of what it already makes coming out of fellowship, but as far as like the bonus structure, the sign on bonus may be a little bit higher for, like, bigger cities because they know. That if you're coming there and like moving stipends and signing on for an apartment or wherever you're going to live, needing like first, last, and for that lease.

So it's a little bit different from that standpoint, but I think overall the base salary is very similar throughout. 

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[00:16:51] Griffin Jones: My impression was that it wasn't proportional, though. Do you think it is proportional? Like, so that the cost of living is so much lower in this, in the smaller cities and the salary isn't that much lower relative to that gap. But you think your read is that it is more proportional?

[00:17:10] Dr. Zachary Walker: I think it's more proportional from what I've seen most recently among my year. I mean, maybe it has changed recently, but most of the salaries. are very similar, like from Texas, Indiana to Pennsylvania and some places in Boston. I think the salaries are, and this may also be with like private versus academic because academic has their kind of salary base here from everybody who's signing for an academic position versus if you were in private practice.

I think the gaps between what people are being offered is between 50, 000 to 100, 000 different. 

[00:17:45] Griffin Jones: And, which to me I guess it depends on, I would, maybe I'm assuming erroneously, but it seems like you could get a house in suburban Indianapolis for six or seven hundred, what would be two and a, two and a half million in suburban Boston.

Correct. So maybe some parts are proportional in some parts are less. So do you think about ways of being able to win the trade off in different areas? Like one of the reasons why I started remote work long before COVID was because I'm from upstate New York. I wanted to stay in a small city in upstate New York.

I wanted my money coming from the. to be more comparable to the larger markets. And I wanted to win the tradeoff. I wanted to have that lower cost of living, no traffic, nice quality of life, but also have that career opportunity that comes from being in a much larger area. And I think that may have been more difficult for docs to do even 10 years ago, but now with the opportunity to, as networks by practices, and then you could buy Equity into that network and you can sit on a seat for that network or you could be a medical advisor board for any of these new Fertility tech companies that are emerging like you can do that from anywhere You can do it from san francisco or you can do it from boise, idaho. Do you think about those opportunities? 

[00:19:05] Dr. Zachary Walker: Yeah, a little bit. I mean, I would say starting fellowship at Boston and having that network, I've been able to connect with a lot of interesting people and have a lot of interesting opportunities presented to me as far as like, being an author for up to date sitting on the ASRM committees and then doing some things outside of that realm as far as mentorship.

And then also I'm talking to researchers in the Boston area as far as collaborating research for new technologies that are coming out as far as like sperm research and analysis, which is my kind of niche and male factor infertility and being involved in that, either like remotely or actually doing hands on stuff.

So I do think that. wherever you are, you can get involved, especially when you're going to these conferences like ASRM and meeting all these different companies that are selling new products and helping them with research or innovation. And you don't have to be in a big city to do that. But I think the biggest issue is that what is your prerogative after fellowship in terms of, are you getting off as I say in terms of academic research and just Focusing on quality of life, private practice, taking care of your patients, and not really focus on research as much anymore and just wanting to be a normal working civilian in a sense.

Or if you're still ingrained in it and want to do research, then you might want to pick an academic job where you can focus on that and not have the constant drive or push to bring in patients for like IVF cycles and have that revenue coming through and you can focus on other things and expand that.

So I think the, as you mentioned, the opportunities are endless. If you're interested in them, they're out there. You have to seek them out and it may be a little bit tougher if you're in a smaller city or not in a collaborating with the big academic institution. But if you have that interest, it pretty much only takes an email or a talk at a conference to get involved.

[00:21:04] Griffin Jones: Now that you are moving towards this next part of your career, what is it that you want to accomplish when you're practicing?

[00:21:12] Dr. Zachary Walker: A couple things, I would say. The biggest one is mentorship. So my biggest thing is that I want to make sure that we continue to expand the amount of fellowship slots that we have available to, one, expand the supply for the demand that's needed in IVF or REI.

In America right now. And I think ASRM is currently tackling that by discussing, expanding the amount of slots at each institution and growing that so that we have that kind of Chain or flow coming through every year and then there are more institutions getting RAI practices. One of my goals while I'm at Indiana is to hopefully be able to foster or create a RAI fellowship with the Indiana University School of Medicine and partner with them to be able to create a fellowship because they have pretty much every other fellowship but the RAI one.

The second thing I want to do is make sure that. We continue to promote diversity within the field of RAI. I'm involved with the Health Disparities SIG in ASRM, and then I'm also on the Education Committee at ASRM. And one of the focuses are diversity in the field as far as patient care and also advocacy and who's taking care of these patients.

I think I was on a meeting with a couple of the diverse RAI physicians. And we're just thinking back to how many people are of color or underrepresented physicians are out there in RAI. And I think it's probably less than 20, and how many patients are underrepresented. Trying to find us or looking for us in the field and most of us are probably in bigger cities So we need to expand a little bit more to smaller cities or other places so that they can still find us or be Represented in a sense and feel comfortable coming to their provider, but you're actually willing to do it

[00:23:04] Griffin Jones: I want to stop on that point for a second Zack because we work in a field where that tends to you know Go one way just in terms of general I guess Dis ideological disposition or political disposition and people say the right things.

But then whenever ASRMs in Baltimore, people are like, Oh, Baltimore is like, it's like, really, what's wrong with Baltimore? 

[00:23:27] Dr. Zachary Walker: Yeah, I agree. 

[00:23:29] Griffin Jones: What's wrong with, what's wrong with Buffalo? What's wrong with Cleveland? What's wrong with Detroit? Oh, okay. So I get it. I get it. Like I grew up in these types of places and you got to have a certain, you got to be able to say like, I'm good with living with.

With less of amenities and or just different ones and having a trade off in amenities but it's like you can't say that we really want equity We really want equality and then do something that Yeah, that doesn't go with that. Yeah, that is part of moving away from the mean, but you're actually doing it though And so like do you does that play into your head?

Like do you think of like are you the type of person that's like f everybody else? I'm actually gonna do it or is it just like no This is where my husband's from and I think it's a good thing to do like do Does any of that chip on the shoulder play in your decision making? Even a little. 

[00:24:28] Dr. Zachary Walker: I I don't know if I, I would like turn myself as a trailblazer and like, say like, oh yeah, f everybody else, I'm just gonna do what I wanna do.

I mean, there are some days I do feel like that when I'm working and I just want to like, like be my own boss. But I think everybody, every fellow feels that way, . But no, I think we do need those leaders who say, Hey, we know that it's a need and I feel comfortable. Doing that or providing that and not feel like I'm going to be going out of my way, because everybody has different backgrounds, experiences, family concerns, family needs that don't allow them to be able to take those steps, and I'm not trying to say that we all need to move in this direction, but I do think we need to make it feel Less, what's the best word?

More comfortable for fellows to do that and not feel like they're being judged about not going to like a bigger practice or joining a bigger company because they're not getting a bigger salary or being able to be a partner at here or there. And I think it's, I mean, the future of REI may be moving in that direction where everybody's joining these big practices and they're expanding and that's the way that.

It's just going to be after fellowship that you just join one of these groups, but I think that we need to have fellows feel more comfortable that you don't have to follow this trend. You can pave your own path and do what you feel is best for you. And for me, going back to Indiana and being able to serve this population, create opportunities for other fellows, create opportunities for the residents that are there and for REI and train them.

That's perfect for me. That's always been a goal for me. So it just seems like a, probably like a perfect fit. 

[00:26:01] Griffin Jones: I also think that establishing a fellowship is a very meaningful, measurable to, to point to and say, I either did it or I didn't do it. And right now there are states, there's plenty of states that don't even have a fellowship.

There's no fellowship in the state of Arizona. University of Arizona doesn't have one, Arizona state doesn't have one. Does the state of Indiana have a fellowship right now? 

[00:26:25] Dr. Zachary Walker: Not an REI. So yeah, it's a, they have like definitely the private practices, but no fellowship. And Indiana university, it's a really great residency program.

So it's, they've had one in the past, but just over the years it got lost. And I think it needs a little bit, some time to come back. 

[00:26:45] Griffin Jones: That would be an exponential benefit, Zach, if you can pull that off, because you're not only bringing one REI to that state yourself, you would be, you'd be bringing at least three in a given year, right?

Plus the faculty, so maybe four, and then maybe every one, four years, one of those stays in the area. And so you could have an exponential impact. How do you think you might get that done? 

[00:27:11] Dr. Zachary Walker: So I think right now, my goal is to try to see what the tone is between my practice, Midwest Fertility Specialists and Indiana University in terms of like partnership or their ways to do that.

As you hear of other hybrid REI fellowships like RMA New Jersey or RMA New York that are with a big institution like Thomas Jefferson or Mount Sinai and they're able to have a fellowship through their kind of private practice but it's affiliated with an academic institution. I don't know exactly how that conversation starts or the kind of the build begins.

But I know Dr. Peipert, who is the chair of Indiana University's OBGYN program and had conversations with him when I was interviewing for to stay at IU. So I'm hoping that through my time there, being able to teach the residents and being able to Take care of patients that we can start to talk about how we can structure a fellowship program and I've reached out to some mentors who are doing it recently.

And I know there's a lot of paperwork that comes with it. A lot of logistics. So I don't think will be easy in terms of getting it started. But I believe when spoke with my current, my future partners at Midwest Fertility Specialists who are interested in doing that. And then also the residency program director at Indiana University, Dr.

Scott, would also be interested in trying to get a fellowship started. So I think the interest is there. We just need to hit the ground running and try to get it started.

[00:28:46] Griffin Jones: I want to go back to the topic of where, of how you sussed out these interests when you were looking at different programs and applying to different programs, but I did cut you off a bit when you were talking and I would just want to make sure there weren't any other core objectives that you mentioned that you want at hoping to add a fellowship, wanting to improve mentorship and also promote diversity and any other core objectives that you're thinking about for how you want to practice.

[00:29:14] Dr. Zachary Walker: Thank you. Oh, so I like the last thing for me is I still like to do research and I'm hoping to continue that even in kind of being in this private Demick center. So I'm currently mentoring one of the Indiana University residents. I'm hoping the best for her when she applies that she matches, but, trying to increase the research that they have available in terms of RAI at Indiana, and then also within my practice, whether it be like IVF techniques or kind of racial disparities care, whatever kind of niche I can grow into, and the fact that when I interviewed at this place and told them my interest, they were also willing to help me with research and were going to give me the space to do that, and I didn't feel that I was going to be the pigeonhole into just churning out IVF patients was a big thing for me to know that I wasn't going to have to give something up readily when I signed this contract and they were willing to work with me in whatever facet or space in the REI world to make sure I felt comfortable joining the practice.

And I think that's a big thing. And I didn't feel like I got that everywhere I interviewed. So when fellows are going out to speak with all these different businesses and companies, and they're telling them this is what your job is going to be, it doesn't, that doesn't need to be the end all be all, you should kind of seek out what jobs are going to work with you to make sure you're not uncomfortable signing this contract, you want to make sure you're getting into a job that's going to continue to expand your mind, expand your thoughts about the world of REI, and provide you satisfaction.

Yeah. 

[00:30:48] Griffin Jones: How much of the interview process was informed by having these objectives ahead of time and how much of the interview process formed your prioritization of the objectives? 

[00:31:02] Dr. Zachary Walker: I was looking back. That's a good question. I will say looking back. It was probably 50 50 So one of the things I do want to kind of Highlight or bring attention to is that as a R.

E. I. Fellow in our first year you go to A. S. R. M. You have once they know you're a new fellow or you're starting off, you'll get all these pulls or emails of what? Where do you want to go after you finish? What jobs are you looking for? Are you interested in this? We have these opportunities and it's overwhelming and you don't even know what you're doing as a first year.

Really? You're just trying to you. figure out what it is to be an RAI, but yet you have all these job opportunities coming to you left and right. And there's a some somewhat pressure to make sure you're not missing out on an opportunity because that's how we're trained as like residents or medical students.

We're very like type A personalities who don't want to miss out on something. So you. Get all these invites and you may jump into interviewing places early before you even know what you really want. And so I fell into that trap a little bit and interviewed probably at the beginning of my second year.

And I, they were asked questions of what do you really want to do when you come out of fellowship? How do you see your schedule? What do you think is the most interesting to you? And I really didn't know 100%. So it didn't start until late, my late second year, beginning of my third year, to where I really knew, okay, this is how I see myself in the future of REI.

And this is what I want to give back and had more meaningful conversations during my interviews about what I wanted and what they can offer and how we could find common ground to do that. We should feel comfortable working kind of signing contracts. It's at a place that, that is going to foster your ideas of what you want to do as an REI coming out of fellowship and also what they would need out of you.

So it takes some time to develop those, that knowledge. It did for me. I don't know for everybody else, but until my third year, I really didn't know a hundred percent what I wanted to do. So I think the more time people take to really Reflect about their thoughts of their future practice and see what is out there before jumping into interviewing would be my best piece of advice for any future fellows looking for jobs to not feel stressed about interviewing and missing out on certain opportunities and take time for yourself because the need is there.

There will be jobs available, but don't feel rushed to sign something so soon before you really know what you really want. 

[00:33:33] Griffin Jones: Sometimes general advice for determining who you want to be in this world involves outlining what you don't want to be. Was there any of that? Did you consider ahead of time what you wanted to stay away from?

[00:33:48] Dr. Zachary Walker: Yeah, and part of this did change a little bit because of all the stuff with my family that was going on, but initially I never thought of myself working in like a Private practice that didn't have research available because that was such a big part of why I was interested in RAI, why I wanted to be RAI fellow was because of the interest, the research was very interesting to me.

So I always thought of myself going into the academic Kind of space to continue that. And when I was interviewing and talking to different places, this private Demex model of this hybrid model was very enticing to be able to say like, Hey, I would still be able to make a meaningful salary. And also do IVF, but still have the ability to mentor, do research, and train the upcoming RAIs for the future was like a perfect fit for me.

And then this opportunity at Midwest Fertility Specialists and collaborating with IU seems like an even better deal. So having that space, kind of headspace of what I really wanted to hold on to. Was important and knowing that I didn't I wasn't going to sign a plate to a place that was going to make me give that up 

[00:34:58] Griffin Jones: How did you suss that out because in interviews people generally especially when they're trying to recruit you know, they're not the they being clinics and networks are not the Beneficiaries of the supply demand imbalance typically they are typically trying to everybody's trying to get their hands on an REI for the most part.

And so people very often be like, Oh yeah, you can do that Zach. Sure. And then it's like, when it actually comes time to do it, people find out they weren't specific enough in their negotiation and then they tend to fall back to maybe later, or no, that's not what we meant or not now or whatever it might be.

And so how did you suss that out of who could provide you with what you wanted the most?

[00:35:42] Dr. Zachary Walker: So I, Part of it was talking to other fellows ahead of me who've signed contracts with those companies or who knew someone who's working with them about what their day to day was like and if what I was being told was true or not.

And I think that went a very long way to have someone on the inside know. What is their day to day? Are they actually able to do research? Are they actually doing surgeries as much as they thought they were doing surgeries or how much of their day is literally? No, you need to sit down and see new patients and bring in as much IVF volume as possible.

So I'm very grateful for the people I know and like my network in the REI field from my co fellows to prior graduates and keeping those friendships close. Another part of it is My practice that I'm joining isn't part of one of the big conglomerates. Not yet, hopefully not anytime soon, but it's not part of the, like one of the big five or whatever.

And I think that is what allowed me to know that they were, I would have more wiggle room to do things because this practice has been in play for over 20 years and they have seen the shifts of all the different RAIs in the state and can. provide me with background on what's possible, what's not possible.

And they felt very comfortable in my goals and my dream for this, for the practice of what I wanted to do. And I believe them. So I think those two things really played in hand to make me feel more comfortable signing the contract and moving forward with them. 

[00:37:13] Griffin Jones: So if they're not part of one of the networks yet, as you say, but how many docs are there?

Four or five right now is five. Yeah, I'll be number five. You'll be number five. So that's a group that one of the networks wants to buy. And I've seen this before is that I have recommended I've helped connect some fellows with their future jobs. And then it's an independent practice.

And by the time they start, it isn't. And have you thought about what it will be like being in a city right now where there's like two, maybe three programs if you go further out versus, if you are in a larger city, if you're in the Bay Area, if it doesn't work out, it This place, you can go to one of 12 other places and in the meantime, you might have, if it doesn't work out at a particular place in a smaller city, you got your kids in school, you bought your house and say, gosh, do we have to like uproot and go somewhere?

Totally. I'll say, how do you think about those terms? Or do you just try to push it out of your head? 

[00:38:21] Dr. Zachary Walker: A little bit of the latter for sure. Just like, everything should work. But yeah, in residency, we had these kind of career talks about how often do people stay at their first job? And it's not that high.

Usually most people will leave within the First three years of their first job because of not liking it or things that were promised were not there. And, that definitely may happen to me, but definitely trying to be as optimistic as possible is my head space. But if it, yeah, if it doesn't work.

I will most likely have to move because of the contract of what's the term I'm looking for? Non compete. Yeah, non compete, yeah. So that may require me to move or not be able to practice for at least a year before I can sign again, which would be definitely very difficult. Like the biggest network of potential jobs would be in Chicago, which definitely has a plethora of REIs.

But. I'm kind of remaining optimistic, moving forward with that and hoping everything works out. I mean, I love the people that I have met for my future job and they all seem very great. They all are very supportive of me, so I'm just hoping it all works out very well. 

[00:39:27] Griffin Jones: It's also part of when you want to do something meaningful, there's a certain amount of risk involved.

I want to go provide access to care somewhere. It's a hard thing to do, which is what makes it meaningful. Hard things have risk attached to them. Hopefully that's it's win for everybody. And I, if you think about, do you want to like buy into the practice? Do you want to, do you want to own equity with whoever you're working for?

Or do you like not having to, have those business obligations? Where do you stand? 

[00:39:59] Dr. Zachary Walker: So I do have a goal of being a partner with the practice I'm with, so that is one of, one of the interesting things that drew me to the practice a little bit more, was that they do have a partnership tract, which I think some of the bigger companies may not offer that anymore for incoming providers, or it's not the same as what other people got in the past.

[00:40:20] Griffin Jones: Because there's not as many of them. Like, there's just, yeah, there's not as many of those types of, I mean, there's different types and they might be good too, but. That old, like, I buy in early, I get some equity, and then I'm part of, I put my sweat equity in so that I'm the beneficiary of a larger share of financial equity later, because I'm not buying it at a discount, I'm not discounting my future profits now, so that It is kind of, I wouldn't say unique, but definitely less common opportunity than it used to be.

But so sorry for my commentary. 

[00:40:51] Dr. Zachary Walker: No. Yeah. That, I mean, that's right. So the practice that I'm working with now just they are, the lab is separate from the clinic. So the clinic has just been bought out by a group called Axia. And even though the branding is different, the Axia women's group is partnered with Midwest fertility specialists.

They are recently kind of renewed contracts and that's when I kind of came in and I'm under this contract with the new group. 

[00:41:18] Griffin Jones: So they are, they are part of a bigger group, but you're just saying they're not part of one of the major fertility networks. They're not like 

[00:41:24] Dr. Zachary Walker: CC. Yeah. Like CCRM, RMA.

Yeah, but yeah, they are part of a group. Yeah, so the, and prior to me being there, they were part of another small group, I forget the name of it, so this turnover to Axia was happening in the past year. The lab, on the other hand, is a part of the Ovation Network of Embryology Labs and IVF Labs, so the ability to kind of buy into both of these practices is possible for me doing the partnership track.

And I mean, it would make sense for me to join right now from a financial standpoint if I can to work to be a part of that for future wealth. But that wasn't always the goal. The goal was mainly for the kind of academic research mentorship ability to create something new for the REI, like REI fellowship at Indiana, which is my primary goal.

So the whole kind of financial things that come with it are definitely a bonus, but they weren't going to make or break.

[00:42:30] Griffin Jones: can't wait to interview you in five years again and do a follow up of this conversation because I wonder if that is what kind of path that will be having the two different opportunities with the two different companies, one owning the lab, one owning the clinic, because often it, we've seen the ovation model before, and often the clinic will stay, you Independent then, and the Ovation owns the lab, then USF acquired Ovation.

And so many of those clinics that were independent, many of them still are those that then decided, Oh, I want to sell the clinic later on, I think would sell to us fertility. Same parent company still, I think of infertility institute originally had sold their lab to Vivera, which then was acquired by Prelude.

And then it became part of the inception and network. And then, but then later on, it was Prelude that, or either, one of their brands, Aspire, that bought, I don't know exactly that bought HFI. So still, again, still mapping up to the same parent company right now, Lab Clinic for you, two different parent companies.

I wonder if that will be complete chaos and you'll hate it or you. Or what I'm hoping, what I'm hoping for you, Zach, is that you are on the, that you have tapped into something like the record labels or the content producers who are on different streaming services, like South Park, is still on this streaming service, but then for these specials, they'll be over on Paramount plus and they can do it and they're benefiting from the different labels and some artists.

Can I'll make this content over here. But when I do my crossovers or I'm with as a solo artist, I'm over here when I'm with the band, I'm over on there. And when we do a crossover, there's a benefit and they're a little bit more diversified as well. So I'm hoping that's the case for you and that you, we'll see.

You definitely pioneered something. 

[00:44:21] Dr. Zachary Walker: We will see. Definitely. I'll check back with me in five years. Might have a little bit more gray hair. 

[00:44:28] Griffin Jones: How do you want to conclude, Zach, about either about expanding access to care either by geography or any other measure or any of the subtopics that we covered today?

How would you like to conclude? 

[00:44:38] Dr. Zachary Walker: Yeah, I think I just have kind of Three main points. One for any future fellows like listening to this podcast, you're in the midst of looking for jobs or thinking about starting the interview process. I would say take time to reflect and don't feel rushed to sign contracts or push to do that.

And definitely make sure you're having meaningful conversations when you're interviewing so that you feel comfortable signing the contract and can move forward with that process. The second thing is for future fellows as well. This is your time to see if you want to get off the kind of academic train and go private practice or continue on and finding like a hybrid model or moving towards just working like a private model and making patient care memorable and taking care of your family and moving in that aspect.

So this is a pivotal moment that we've never had before in terms of this isn't a match process. This isn't a put an algorithm. This is literally. your opportunity to pave the way for the rest of your future. So definitely take advantage of that. And then definitely the last thing is we do need to expand our access to care and making fellows feel comfortable moving to smaller cities or other areas to be able to provide that care.

So hopefully this interview will make other fellows who are interested in that endeavor feel more comfortable. And doing so and seeking out opportunities for themselves to be able to grow in their space. And yeah, thank you so much, Griffin, for having me on this show. This is amazing. 

[00:46:12] Griffin Jones: That's my pious hope.

Your wish at the end there, Zach. That's my pious hope. I haven't really been able to do it, so I'm hoping that giving you a tiny megaphone is able to do it more. Dr. Zachary Walker, thank you for repping small cities. It's been a pleasure to have you on the show. 

[00:46:26] Dr. Zachary Walker: Thank you so much. 

[00:46:27] Sponsor: This episode was brought to you by MyEggBank, the premier network of donor egg banks.

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185 How to Increase the Number of REI Fellow(ship)s. And some ideas for Funding with Dr. Rachel Weinerman


Everyone says we need more REI Fellows, but how do we get them?

In this episode, Dr. Rachel Weinerman sheds light on what is required to make more REI Fellowships and Fellowship Programs, and why those two solutions aren’t exactly the same. Dr. Weinerman talks about:

  • Creating REI fellowships: Exploring the steps in establishing robust REI fellowship programs.

  • REI fellowship funding and operation: What Medicare pays for vs what the institution pays for.

  • What an REI must do vs what another ‘IVF specialist’ can do

  • Specific resources that SREI and ASRM can contribute to Fellowship growth

  • ACGME’s role vs ABOG’s role in accreditation and certification

  • The limitations and scarcity of Privademic Partnerships


Dr. Rachel Weinerman’s LinkedIn
Company Website: uhhospitals.org

Transcript

Dr. Rachel Weinerman  00:00

So where are we now in 2023, we have comprehensive training programs that train OB GYN who are already fully trained OBGYN to become reproductive endocrinology and infertility physicians. Now, I said reproductive endocrinology and portfolio positions. This is very different than training an IVF physician


Griffin Jones  00:28

Who the heck is going to pay for all this? Today we talk about Rei fellowship programs and Rei fellows answering those two questions because they're not exactly the same question. The question of how you get more Rei fellows isn't necessarily the exact same question as how you create more fellowship programs. But we do talk about both of those questions. My guest is Dr. Rachel Weinerman. Dr. Weinerman did her fellowship at Penn. She's been at university hospitals in the Cleveland area since 2015. She's been their program director for the fellowship program there since 2021. And she's got some ideas. First, I kind of poke at her for a little bit. And I make us spend some time on this question that we've talked about a lot on this show, which is what does an REI need to be doing versus what does the IVF specialist need to be doing? Because very often, we approach that question from the other way, the way we usually approach that question is how much Rei training does an IVF specialist need to have? So I tried to take that question from the other way. And I made us spend some time on it even though it isn't the main topic of this episode, because I wanted to try to isolate how important is the scarcity of REI fellows? If the volume question isn't at play, if technology solves for a big chunk of the volume question is the lack of Rei is still a problem. I wanted to isolate that and I think we did successfully then we started to get into the steps of setting up an REI fellowship starting with the roles what's a Boggs role, what's ACGME his role, we talked about ACGME rules. We talked about Medicare rules, we talked about what Medicare pays for not a lot. And then we talked about what the institution pays for. And that got us in more to the costs of running an REI fellowship program, the irei salary, their insurance, their mail, practice their benefits, paying for program coordinators, paying for other conferences, training capacitation and other professional development. Finally, we talked about who's going to pay for all this and what are some ideas ideas, including allow Rei fellows to perform those services for which they can build up to the capacity for which they're allowed to build national organizations like ASRM and Sri possibly contributing to a fund and things those national organizations can do beyond just funding like standardizing a didactic curriculum suggested rotations and we talk about this trend of private Demick partnerships, but also their limitations. Why have we only seen some of them and not an explosion of everyone doing them? Everyone seems to agree that we don't have enough Rei is coming out of fellowship, regardless of where they stand on how much Rei training they think IVF specialists need. I've never had anyone argue the opposite, that we have too many Rei fellows or that we don't need more if you do have that viewpoint, you're welcome on the show. But this is a problem that everyone seems to have consensus from that I can tell. And so I hope you enjoy Dr. Weinerman's insights on why this is happening and what we can do. Dr. Weinerman, Rachel, welcome to Inside reproductive health. Thank you. It's a pleasure to be here. You were a profile of person that I wanted to get to know that I am glad I've gotten to know this year because I really am interested in how the REI fellowship works, how we get more of them. What's necessary what's not necessary because I'm not a clinician I can't get I don't have a dog in this fight of that we should be training OBGYN to do A and Rei is don't need to be doing B I can't really opine. I can only facilitate the conversation and try to pull in as many points of view as I can. You are a bit more qualified to opine. And so I want to start with just let's start with the importance. What are the important things in your view that REI has learned in fellowship that can only be learned in Rei fellowship? 


Dr. Rachel Weinerman  04:05

Yeah, great question. And thank you for having me on the show. I want to start by saying that my opinions that I express are my own. I'm not representing any official organization within the world of Rei. I am program director. So that makes me I hope qualified to discuss this topic, but I'm really sharing my own opinions. So first of all, let's think about what is the history of REI training. So Rei fellowship has existed since the 1970s. When these evolved and adapted, you know, in 1974, when the first board exam was given in Rei IVF didn't exist. So what we've done in training our REI has obviously evolved in the last 40 plus years. So where are we now in 2023. We have comprehensive training programs that train OB GYN who are already fully trained obyns. To become reproductive endocrinology and infertility physicians. Now, I said reproductive endocrinology and fertility positions. This is very different than training an IVF physician. Because what we're trying to accomplish in an REI fellowship is to train subspecialty physicians who are experts in reproduction, who can serve as consultants to general OBGYN and other physicians, and who can provide comprehensive clinical care and infertility and other reproductive disorders, as well as innovate and move the field forward. So that we are constantly improving our knowledge and what we can do for our patients started. That's the overview of how we frame our fellowship training. And I think that really informs what we do in a fellowship. 


Griffin Jones  05:48

So how much of a rabbit hole do I want to go down? Now? I guess I will touch it a little bit that where someone who is doing IVF doesn't necessarily need to be in Rei, are you simply making the distinction that Rei is a lot more involved than just IVF? 


Dr. Rachel Weinerman  06:03

I would say the latter. I think that currently the way that we structure IVF practice in this country, and we can discuss whether that's going to change the future or not, in order to practice IVF, with the full depth of the field, you have to be trained as an RBI physician, and ri physician doesn't just do IVF. But the knowledge that you get the depth of experience that you get informs your ability to provide proper care in IVF. To put it up maybe a little bit more specifically, the way that I train my fellows. I want them to be able to be creative, and how they provide IVs care, I really don't want them to practice algorithmic medicine. And in order to do that, you have to understand the basic physiology, you have to understand what's happening at a molecular and cellular level, in order to make decisions that best account for the information that you're getting in real time.


Griffin Jones  07:03

 Is that at odds with an operational scaling system, I had one guest, a CEO from a fertility network in India that that that episode will almost certainly have aired before this one does. And he was speaking about their network has one set of protocols, there's one protocol per patient profile, and they have 250 physicians. Now there isn't an REI fellowship in India. So these are OBGYN physicians, but they have 250 in their network, and they're all practicing from one set of protocols. And I said, I have worked with two Doctor Rei groups in the US that have different sets of protocols. And so is what you're saying where you don't want your Rei is necessarily practicing algorithmic medicine. Is that odd with a scale of operations of something like having one set of protocols?


Dr. Rachel Weinerman  08:05

That's an excellent question. And I think this gets to one of the biggest questions within medicine is do you practice based on what we call standards or algorithms? Or do you practice based on individualization? And I think that in America, we have excellent outcomes. And IBM, obviously, they couldn't always get better. And what accounts for our excellence? Well, there's many, I would say many things. But I think one of them is our ability to provide high quality of individualized care. Now, that's different, right? In large practices versus smaller practices. And you might say that large practices do have more of a focus on standardization, which is another word for algorithm. But when you have physicians that have that in depth training, they can pin it. So the way that I tell my fellows is, you can do the first cycle as an algorithm. Right, but in that first cycle is successful. Great. But if that first cycle is not successful, what's going to be your next step? How are you going to pivot and change your treatment plan to account for what happened in that cycle? And that that's very difficult to create algorithms that account for each situation that you might encounter.


Griffin Jones  09:14

So that's on the side of, of how much RTI training should IVF specialists be able to have or at least be involved in? How much else should RBIs be doing beyond? IVF? So I'm thinking of the question this wave, when we have David Stabler and a number of others, I will say we're doing about 200 250,000 IVF cycles in the US we need to be doing somewhere around 2 million perhaps more than that. And, and so that is to suggest that we need more IVF being done, but if there are other ways of being able to scale IVF what else should RBIs be doing beyond IVF?


Dr. Rachel Weinerman  09:59

That is Excellent question. I don't think I have all of the answers to the scalability question, because I think that that might entail a significant reimagining of how we provide care. So I think that's an excellent question. I don't think I have a very specific answer to it. Because I think it's a really philosophical debate about how do you provide infertility services and IVF. Specifically, what a reproductive endocrinologist is trained to do, and we were able to do after fellowship is provide comprehensive care. So that means that if a woman comes with irregular periods, with abnormal reproductive hormones, with fibroids with malaria, and abnormalities, all of those can be addressed in a way that allows her to proceed with her reproductive goals. So that is what every doctor of endocrinologist can do. Can that be broken up from IVF? Again, I don't know the answer to that question specifically, but you can't provide full comprehensive infertility care without those additional areas.


Griffin Jones  11:05

What distinguishes our AI train doctors from other physicians in the field of infertility?


Dr. Rachel Weinerman  11:14

Yeah, great question. So I'm going to assume that what you mean by other infertility physicians are OBGYN,


Griffin Jones  11:21

OBGYNs are, yeah, almost almost certainly OB GYN 's or I guess, advanced practice providers working with OB GYN.


Dr. Rachel Weinerman  11:28

Right. So those are two different categories. So advanced practice providers typically have two years of schooling, after college, and then they don't have any formal clinical training after they graduate their program. So a lot of knowledge gained by advanced practice providers is going to be in the clinical setting on the job, what you might think of as an apprenticeship. And they are trained for the clinical work that they'll be doing, but specifically by who they're working with. So that might their practice styles may change. And then the depth of knowledge that they have is obviously different. And OB GYN will have completed four years of medical school and a four year residency in OB GYN and they they have you know, significant more depth of knowledge, their experience in Rei specifically, may be more limited. Most OB GYN residencies require at least a month of REI training, but sometimes it's only a month. So that's, you know, they obviously have that expertise in many areas with an OBGYN, but they may not have that depth of knowledge to be able to practice infertility and a lot of that learning that would require that would be necessary if they were to practice infertility would have to come after training,


Griffin Jones  12:37

I'm thinking there's a few Fertility Center practice owners that I can think of that were sort of grandfathered in prior to fellowship requirements that never had an REI fellowship. And then there are others that I can think of that work in fertility practices they work with and under an REI in many cases in they have for years, but they never had a fellowship. And and so I don't believe that they're board certified because you need you need the fellowship in order to take the boards, right. You can't.


Dr. Rachel Weinerman  13:07

Yeah, so I can go over that in more detail for you.  Yeah, this question of okay, you have some Doc's that were grandfathered in. And you have other Doc's that maybe they weren't grandfathered in. They're still working with REIs, but they've been doing it for 15 years. And so what does an REI fellow What does someone gain in Rei fellowship that they might not have gained? Well, first of all, is a great question. We do have doctors who are grandfathered in, I would say many of them are older, you know, pre board certification for i o that that is tend to be phased out. You know, 15 years is a lot of experience. I would say a lot of OB GYN working now may not have that length of experience going into an infertility practice. But let's talk for a minute about what Rei fellows do do and fellowship. Currently, fellowship is three years in the past used to be two years, there's some discussion about whether that link should change. Fellows are they do at least 18 months of clinical rotations, that includes training in infertility and what we call a RT, not just IVF. They do surgery. They do genetics, they do male infertility, endocrinology, pediatric endocrinology, and increasingly spending time in the IVF laboratory learning IVF techniques, then they spend at least 12 months doing research. And that research culminates in a thesis called a scholarly thesis that has to be presented. And it represents a significant scientific effort, which demonstrates knowledge not only of the scientific literature on the scientific method, but how to critically appraise what is happening in the world of scientific knowledge and Rei, and how did you innovate in that field that demonstrated by doing that type of project, and then they typically also have six months of electives, which can be individualized to the fellow and their and their training requirements. So that's The overview of what they do in order to then actually practice within the field of REI, they have to take a an exam from the American Board of Obstetrics and Gynecology, it's actually two, they take a written exam called the qualifying exam. And then they take an oral exam, which is the certifying exam. after they graduate, they collect cases for 12 months, and submit their case list along with their thesis in order to sit for the exam. And then they take the exam, which is a three hour oral exam.  So there is a breath that people are learning in the REI fellowship program. And that takes me back to the question of what else should always be doing and I thought of a different way of asking the question. So if we're doing 250,000, IVF cycles or so we should be with 1200 RBIs. And plus probably some others, because that almost certainly includes OBGYN who are part of that process. But let's just say we've got 1200 RBIs in in the country right now doing 250,000 cycles. If with technology with training other Doc's and other positions, massive operational improvements in the next 10 years, we are doing 2 million IVF cycles from 1200, RBIs, or even fewer. What I'm saying is right now a lot of the argument for increasing the number our very eyes is because we need to to meet the demand, let's just pretend that we can meet the demand with with the improvements that happen over the next 10 years. Do we still need more REIs, then if we're if we're seeing if we can meet the IVF demand? Do we still need more areas? And if so, what for? So I would I would answer with a resounding yes. I think we need more. And I think what I'm when I'm describing about Rei fellowship, and the intensity of fellowship and the value of fellowship, doesn't change the fact that we don't have enough REIs. And we can talk a little bit about some of those impediments. Why we don't have as many Ira fellowships as we do, how do we train more Rei fellows. In the end, in order to practice quality medicine, you need more REIs, even if those Rei are supervising they advanced practice providers or other physicians that may not have Rei specialty training, in order to scale up as significantly as you're describing, you would still need more REIs in those roles, they may not be always providing the direct care, like they may be supervising other providers. And I would say that that's an appropriate role. But if you don't have an REI involved in that supervision, then likely the quality of care will not be what we want it to be. And the innovations won't occur.


Griffin Jones  17:41

Is there anything else beyond supervising IV? Is there more research that needs to be done? Is there more? Are there other areas of medicine that era is should start to be? I guess I don't know what the word would be cross discipline with is beyond supervising to meet that scale? What other responsibilities should the REI take on if AI and all of these other technologies and systems do in fact, and I understand it's a big caveat. But Fiat that may for a moment, and what else should they be doing?


Dr. Rachel Weinerman  18:15

So let me put it this way. There's a debate within the world of REI as to how much that II shouldn't be there. Right. Rei is reproductive endocrinology and infertility. How much should the REI focus be on endocrinology. That's historically what the field was, again before IVF existed, you know a large role that that the RBI had was in managing hormones. Now we still do. But that looks different now that we have AR t as a huge component of what we do. So should that E be replaced with for example, a G for genetics, a lot of what we do now is involves very complex genetic information, both from the perspective of the patient and the patient's partner, and from the perspective of the embryo. And the information that we're getting is, is enormous, it's complex, and it's changing. So to be able to adapt to care for patients in this changing environment, that is an area of focus that Rei might consider in the future. The other question is gynecologic surgery. And that historically has been a very important part of what Rei is do and is still a very important need. There are many patients whose fertility needs cannot be solved with AR T alone. They need surgery in order to be able to accomplish a successful pregnancy. And that historically has been the role of Rei. There are now more widely invasive surgeons within the world of GYN who do some of that surgery. That I would say is an open debate. There's many different opinions. I personally work at an institution that is very surgical heavy, and we are able to provide that type of comprehensive care for our patients. So let's say what else could REI be doing? I would say those are two areas that I would say we have to think about how much we want REI involvement. And then I would say what you mentioned about research is extremely important. I use the word innovation before. And I think that, to me, research is a prerequisite for innovation. If you don't have people trained in being able to perform research, and assimilating all of these types of complex data, you will not see innovation in the future, you will not see improvements in pregnancy rates, you will not see improvements in the what we are able to provide, I don't know what IVF is going to look like 40 years from now, I hope it looks very different than what we're doing. Now, I always tell my patients, you know, I have to give them the option of donor egg, for example, now, because they don't have, you know, any egg reserves to be able to get successful autologous IVF, I hope that's different, you know, by the time I retire.


Griffin Jones  20:57

the reason I kept poking at that is because I said, this kind of Nexus where there's a lot of venture capitalists and private equity people, as well as fertility practice owners and doctors. And so and and see them come together, and I see them having conversations, a part of one of the conversations that is coming from the doctor, and is well, what do we do if AI is really able to scale us up to this level? If, if other doctors are able to do these procedures, if we're able to use technology and systems to answer a big chunk of the volume question, then what is it else that we do? And and so where your mind went with that is, is the answer that I've been looking for it to that is because there's going to be something for you all, I try to tell the REIs don't freak out, it's just going to be, it's going to be different, I think you're going to be doing just fine, no matter what happens, but I think it will be very different to 10 or 20 years from now. And I'm neither a clinician nor a futurist. So I have to pull it out of I have to make people like you speculate in order to try to paint a picture, in that you started to talk a little bit about why we don't have enough programs. And I in my view, I'd say we we don't have enough. We recently inside reproductive health wrote an article, the journalist interviewed you. She also pulled up some numbers on the number of programs. And I think the according to the National Resident Matching Program, there were 49 Open fellowship positions in 2022. And I want to say that was like from 41 rei fellowship programs, according to that same that that same national Resident Matching Program, so why isn't enough? Why isn't it enough? Why don't we have more?


Dr. Rachel Weinerman  22:42

Excellent question. I don't think I have all the answers. Do you know why? Why don't we have more, but I can begin to explain from our perspective now. Maybe you know what some of those answers are? I would say that the answer your first question is we do not have enough. And I think that is that is a consensus, I would say among most RBIs we need to be training more fellows to be able to provide high quality, fertility services and our guy services in the future. Why don't we have enough? So let's start with a little bit about how Fellowships are structured, who pays for them? And I think that might answer some of the questions. So first of all, infertility Fellowships are under the rubric of what's called the ACGME, the Accreditation Council for Graduate Medical Education, and a bog, which is the American Board of Obstetrics and Gynecology. So with our long names, but essentially ACGME accredits programs, you know, allows them to function and then fellows are certified by a bar. So those are the two organizations that are in charge. In order to be an ACGME approved fellowship. There are a lot of requirements. In fact, there are I just looked at the program requirements before our session today, there is a 56 page document of everything that a program has to do to have a Rei fellowship. That includes being under the rubric of a sponsoring institution that has an OBGYN residency. So you can't have a fellowship without being embedded in an OB GYN residency, which is essentially most likely either an academic institution or a large institution that can sponsor that. And you need to have a program director who has dedicated time program coordinators who have dedicated time you have to have ancillary services in many other specialties. Medical endocrinology, pediatric endocrinology, genetics, male infertility, full operating room, full hospital privileges, access to the medical literature, I mean, the list goes on. So you can imagine that this is not an easy thing for lots of institutions to do. And it takes about two years to get a fellowship up and running. And then the second question that I I alluded to was, who pays for this? Because it's expensive to run an REI fellowship fellows typically costs somewhere between 100 and $150,000 a year. Some of that money comes from Medicare, actually, Medicare pays through direct and indirect funding to hospitals. But the number of fellows or residents that can be paid for through Medicare is actually capped. And those numbers are capped based on 1997 Trainee levels. So it's very difficult to get funding from Medicare for a new fellowship. And so often, that funding comes from the sponsoring institution, whether it's the hospital or or practice. And it makes it challenging because fellows actually can't bill for their time. So your training fellow, but that fellow is not going to make you money in the short term, because fellows have to be supervised, and you can only really bill for the time spent by the attending physician. So they're not making you money, you're spending money on them. It's an investment, but it's not an investment that everyone can do. So I'd say the combination of the logistics of running a program and getting it off the ground, the requirements, which are significant in terms of what the ACGME asked for in a program, and then how to pay for fellowships are some of the contributing factors. 


Griffin Jones  26:12

And when you say it's an investment to train fellow fellows when they can't build for time, it's an investment but very often it's an investment for someone else, isn't it? Right? You are you're the one training them but in many cases, they're gonna go work for someone else, you're gonna go move to whatever part of the country they want it to go to, or people do stay where they went to fellowship sometimes and there is perhaps an increase happening. I don't as we see more of the of the private academic partnerships, but of people staying at least within that organization, maybe I suspect that there is is the limitation in not being able to have more private partnerships that the reason I asked is because when you say that they have to, you know, they have to have an OBGYN residency well, almost every teaching hospital does now I am I you know, I think at the University of Buffalo I think of places like Stony Brook Binghamton and University of Arizona, Arizona state. They all have medical schools and and OBGYN residency. So I believe almost every place that that does, that has a teaching hospital has an OBGYN residency program. Right. So it seems like there's still a whole there's still a whole pool in that group that could qualify. Is it that people that don't have that partnership with an academic institution that can't bring on a fellowship program for that reason? Is that the limitation?


Dr. Rachel Weinerman  27:42

It's one of them. So yes, there are many OB GYN programs out there that do not have attached ROI scholarships. I mean, right. There's only 49 fellowships, there's a lot more OB GYN residency. But if you are a very high volume, private practice, and you you think, hey, I need more Cielos let me open up my own fellowship so that I can train fellows, have them stay on hopefully, in my practice and build my practice that way, you then have to seek out an institution that has an OBGYN residency to partner with, in order to accomplish that,


Griffin Jones  28:15

how much infrastructure is required for that? Because I can think of smaller practices, maybe two to four RBIs that are in the backyards of a lot of these, these hospital systems or medical school, they do have OBGYN residencies, why can't they it seems to just be right now be the larger institution. Can you talk to us a little bit more about what else would go into the infrastructure that would stop a smaller practice group from linking up with a hospital system?


Dr. Rachel Weinerman  28:43

Well, I think that if you have willing partners, you can do it. I don't think that there's a lot of hurdles necessarily to a smaller practice looking at what the bigger hospital system, if there's a willingness on both sides, you know, the hospital then may want their residents to rotate with that practice. And by the way, every OBGYN residency program has to have a relationship with an infertility or Rei division, because it is a requirement of their OB joining residents to rotate on Rei. So I'd say most OBGYN residency programs do have a relationship in some form, with an REI program, you know, either whether it be IVF or an academic Rei division. So I don't know that that's necessarily the hurdle. I think the hurdle is that it takes time to to train fellows, it takes time to set up the fellowship, it takes time to run the fellowship. And there's not a lot of financial incentive for that practice to to pay for that fellowship, unless they know that they are going to be successful in recruiting and retaining their fellows. And in the past, you know, that was actually I would say a negative right people didn't want to retain fellows there was not a not enough spots. They didn't want to train their competition. Now obviously, we're in a slightly different, significantly different situation. So maybe we just need to catch up to that. But I think that the amount of time and the amount of money invested is an impediment to small practices, who may not be able to devote those resources.


Griffin Jones  30:10

Do you think I'm making you think on the spot because I'm just hatching this idea in my brain right now. But the debate that goes back and forth about how much OB GYN should be allowed to do versus how much RBI should be able to do if you were allowed to bill for fellows because OBGYN 's were allowed to do, and there's certain parts of the procedure or they were allowed to bill at the same rate, or I'm, that's beyond my paygrade of the knowledge that I have in that area. But if that were, if it were the case that OB GYN 's were able to build more at what our eyes are able to maybe they are already, but if that were the case, would that then allow for fellowship programs to bill for Rei fellows, has that ever been discussed? And might not thinking of something else? Is there something unethical in there that I'm missing? 


Dr. Rachel Weinerman  31:06

So great question. And no, it is not unreasonable to think about, in fact, one of the challenges that we have now within REI fellowships is we have to think creatively about how to get more fellows thoughts out the most fellowships in the country probably have the capacity to train more fellows, and they're currently training. So I know that's true. In my fellowship, I trained one fellows a year, I could easily train two fellows a year, you know, double the number of fellows that I'm training, I could probably even train more than that, you know, based on the volume that we do in both Rei work IVF work and surgery. The main reason I can't Well, there's two, one, you have to get approval from the ACGME. But assuming that you can do that, it's the it's the funding, how do you pay for those extra fellows? So that's something that we are, everyone I think is thinking about that now I'm thinking about it, there is one slight impediment to what you're discussing, which is the regulations that govern what an ACGME approved fellow can do. So within an OB GYN fellowship, like REI, cellos, can bill independently for four hours a week and their primary specialty. So a fellow could do GYN clinic, pap smears, you know, irregular bleeding, anything that is restricted or not part of REI training, they can do for four hours a week. And so there, I think that is an idea is to have fellows Bill independently during that time, and then not be enough actually to pay at least part of a salary salary for all of our fellow sellers. So I would say that yes, that is a that is a good idea. There are some limitations to it. But if done well, in a way that is respectful of what the fellow is there to do, which is to be trained, that that might be a way to allow more fellowships to have additional fellows or to allow new fellowships to start


Griffin Jones  32:54

that up to four weeks in the specialty that they are already board certified in, that they're allowed to bill for? Is that too much of a distraction to their current fellowship? Would that take them away from what they're supposed to be training for in the first place?


Dr. Rachel Weinerman  33:10

Right, so So four hours per week, just to be just to be clear on that. It's what the ACGME specifies. Now, I mean, that's, I guess, a philosophical question. Personally, I think that if, if you're allowing more OB GYN to train as Rei Sallows, I think that half a day a week is reasonable. So I think it probably would not detract significantly from the fellowship, and I think it would allow more fellows to be trained. So I think that's, that is an idea that, you know, I'm thinking about incorporating into my own fellowship.


Griffin Jones  33:40

So it's ACGME that makes the ruling that fellows are not able to bill for the subspecialty that they're training for is that


Dr. Rachel Weinerman  33:50

it's actually it's it's Medicare rules. So because Medicare is paying for, for resident and fellows, we called trainees then they can set guidelines in terms of what fellows can and residents can build.


Griffin Jones  34:04

And this is true for all fellowships as gufram I found this is true for fellowships outside of OBGYN is


Dr. Rachel Weinerman  34:10

correct. This is true for all residents and fellows in the country that are under the auspices of ACGME. Now, what ACGME specifies for Rei specifically, is how many hours an REI fellow can work in OB GYN, what they call their primary specialty.


Griffin Jones  34:26

So I've never actually compared the lack of fellowships and our view to that of other fields is every subspecialty or almost every subspecialty having an issue where they feel that they're not able to produce enough fellowship programs or trained enough fellows per fellowship program or as this how unique is this to REI?


Dr. Rachel Weinerman  34:48

I think it is somewhat unique to REI, and there are you know, most other specialties outside of OB GYN have larger fellowships, you know they might train five fellows a year eight bells a year are fellowships were set up in the beginning, almost more like apprenticeships and so having one fallow became the norm. You know, for each program, it was not necessarily the case for other fellowships outside of OB GYN within OB GYN. It is it is more similar in the sense that most OB GYN fellowships don't have more than one or two, maybe three per year at most institutions. But the number of MSN fellowships, GYN oncology fellowships, female pelvic medicine, fellowships, have all increased much more significantly than the number of REI fellowships.


Griffin Jones  35:35

The reason I asked is because perhaps if this was more endemic to all fellowships, then there would be more likelihood of perhaps Medicare adapting rules set, maybe you could bill partially for whatever it might be, but it's less likely to see any type of change from Medicare, if it's just the field of REI, or only a handful of fields that are having this challenge. So can you talk to us a little bit about the specific costs and probably by the time this episode airs, we we will have aired a or we will have ran another article where the same journalist did it follow up follow up to the to the first article talking about setting up Rei fellowship programs. And it was very difficult for the journalists to to button down some costs. And we had some quotes from your colleagues to talk about a little bit of what goes in to the variables of those costs. But try to walk us through that as best you can. Variables be damned.


Dr. Rachel Weinerman  36:33

Right. So I would say first of all fellows, you know, they don't make a huge salary, you know, especially given the level of training, what they could be making, if they were, you know, at working in independent practice after they graduate from an OBGYN residency program. But typical fellows salaries, probably somewhere around $75,000 a year. So that's a direct costs, then you have the cost of benefits, you know, health insurance malpractice, which is paid for by the institution, you have costs associated with the program, for example, you know, paying for the program directors time and the program coordinators time, there are resources that you need in order to have that program such as access to the medical literature. So if you're in a big institution, academic institution, which you know, a lot of programs are, then that's not necessarily a problem. But if you're in a smaller institution, that might be at an additional costs. And then you have the cost of a fellow education. So you, you know, you are paying for fellows to go to conferences, you may be paying for your fellows to get a master's degree in clinical research or translational research or public health that you know, includes tuition. And then you are also paying for additional educational resources for your fellow. So obviously, that's how the costs can add up to, you know, over $100,000.


Griffin Jones  37:50

And so, in, in your view, what do we need to do in order to be it are the things that can be done right now to get more fellowships? Online? Does it all lie with the institution having to figure out a way to pay for it? Are there other things that we can do right now to get more fellowships online?


Dr. Rachel Weinerman  38:13

Yeah, great question. So I would say, again, this is my personal opinion, but I think that in order to get more fellows, right, which is different than more fellowships, I think that we need to think creatively about how to pay for fellowship. And I think that one of the, we talked about one of the ideas, you know, having sponsorships by you know, national infertility organizations or private organizations, to fund individual fellows or individual fellowships would also be, you know, a great way to immediately get more fellows how to get more fellowships, is to lower the hurdle for entry. Now, that has to be done in a very conscientious way. Because if you're lowering the hurdle, you know, significantly, everything that we talked about, for why Rei fellows are trained in a way that is unique and important for the field are not going to exist. So you have to lower the hurdle in a way that maintains the quality of the education. And that can be done by you know, for example, saying that we are going to provide resources for program directors to you know, maybe have a way of submitting their application without spending hours of their time reinventing the wheel. It might need, you know, lowering the the administrative burden, which the ACGME is already already working on. It could also mean providing standardized resources from national organizations that can be almost like a toolkit. Here's how you start an REI fellowship. Here's a didactic curriculum. You know, here are some common rotation goals. So that way someone can say, okay, great. I want to start an IRA fellowship. Here's how I do it. I think that that's a big challenge right now. And I think that making a more systematized way that we can provide support for organizations to start a fellowship, in addition to financial resources, I think would be very important. And we could do that soon. We could do that and probably increase the number of fellows immediately fellowship, like I said, takes about two years once you apply in order to actually see that come to life,


Griffin Jones  40:18

when you mention national organizations, are you referring to the ASRM? SREI, Who who are you referring to?


Dr. Rachel Weinerman  40:26

I would say those are, those are prime examples of who could provide that oversight. SREI is a national organization that provides oversight for the fellows. So I think SREI is a great organization that can help with some of these proposals that I'm suggesting, which are more, you know, a more standardized approach to starting a fellowship or the resources to run the fellowship.


Griffin Jones  40:47

And so when you say, so if they were to include if they were to help pay for some of these resources and pay for more fellows to come in? Many of those organizations get some of their funding from sponsors. Is there any kind of legal framework that you're aware of that would prohibit let's say, ASRM starting a larger fund for to contribute to more fellowship programs, if it was funded by pharmaceutical companies or genetic testing companies or, or others? Is there anything that prohibits that?


Dr. Rachel Weinerman  41:21

Not to my knowledge, but I'm not an expert in that area? So I would probably defer to somebody from a theorem or Sri to answer that question.


Griffin Jones  41:28

I'll save that question for next time. I have Dr. Robbins on the show as the first first question he's getting ambushed with next time. So and when you talk about having more fellows per fellowship program, you said you could easily do two a year perhaps even more than that. You said that ACGME first needs to approve that how how hard is that is the only reason why people aren't doing more of that right now, because of the cost or are there other hurdles that AC ACGME puts forth? Other than cost to say, No, you can only have one fellow per year?


Dr. Rachel Weinerman  42:07

Yeah, I would say both, I would say probably the main impediment is, but there are significant challenges to trying to increase the we call the complement of fellows. The ACGME wants you to demonstrate that you have sufficient clinical resources and research infrastructure to train that additional fellow men, sometimes they can be picky. So you may think that you have the capacity to train additional fellows, the ACGME might not agree. So I think that is that is a challenge for some fellowships. You know, that's something that we could advocate for, you know, within the field of REI, but I would say that that that probably the answer is both.


Griffin Jones  42:41

Well, you've walked us through quite a bit about how fellowship program gets off the ground, what we could do to get more Rei fellows and more Rei fellowship programs, viewing them as part of the same problem, but two different questions. How would you like to conclude on this issue?


Dr. Rachel Weinerman  43:00

I would say that you're asking an excellent question at a very relevant, I think we are at a crossroads in the field of our AI, we know that the demand for what we will be doing is going to be increasing exponentially. We know that there are challenges that come with that type of growth. And we know that there are going to be many different changes both in terms of technology and in terms of who provides care. I think at the heart, being an REI physician means that you have significant understanding of the reproductive system, and are able to implement changes in innovation and how they provide infertility services. I don't think the role of the REI is ever going to go away. I think that we just need to work very creatively to expand the number of fellows that we're training without sacrificing that level of training, and incorporate Rei trained physicians into a larger team in order to provide excellent care for our patients and hopefully adapt to the needs of the future.


Griffin Jones  44:02

Dr. Rachel winderman REI Fellowship Program Director at University Hospitals, thank you very much for coming on inside reproductive health.


Dr. Rachel Weinerman  44:09

Thank you so much. It's been a pleasure being here.


Sponsor  44:12

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are 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